The Care Quality Commission
  • Doctor
  • GP practice

Carlton Group Practice

Overall: Good read more about inspection ratings

Carlton Street, Burton On Trent, Staffordshire, DE13 0TE (01283) 511387

Provided and run by:
Carlton Group Practice

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Carlton Group Practice on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Carlton Group Practice, you can give feedback on this service.

17 August 2021

During a routine inspection

We carried out an announced inspection at Carlton Group Practice on 17 August 2021. Overall, the practice is rated as Good,

Safe - Good

Effective – Requires Improvement

Caring - Good

Responsive - Good

Well-led - Good

Following our previous inspection on 11 February 2019, the practice was rated Requires Improvement overall and for key questions safe, caring and well-led.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Carlton Group Practice on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a comprehensive review of information with a site visit inspection to follow up on a breach of Regulation 17 Health and Social Care Act 2208 (Regulated Activities) Regulations 2014, Good governance.

This was because:

There were gaps in the practice governance systems and processes to ensure compliance with requirements to demonstrate good governance.

In particular:

  • There was a lack of a systematic approach for oversight of records of skills, qualifications and training for all staff.
  • There was no system in place to follow up children's non-attendance at secondary care appointments.
  • The safeguarding policies did not reflect updated categories of abuse.
  • The practice lacked a clear audit trail for patient safety and medicine alerts patient searches. The arrangements for identifying, recording and managing risks, issues and implementing mitigating actions were not operated effectively.
  • Infection Prevention and Control processes had not been adequately applied at the King Street site.
  • The practice did not have risk assessments in place in relation to medicines for use in the event of an emergency not held at the practice sites.
  • The practice had not ensured that both practice premises had appropriate documented health and safety and security risk assessments in place. However, an external company was employed to undertake these assessments on 15 February 2019.

At the inspection in August 2021 we found that the provider had satisfied the requirements of the regulation.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Conducting staff interviews using video conferencing
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider
  • Reviewing patient records to identify issues and clarify actions taken by the provider
  • Requesting evidence from the provider
  • A short site visit
  • A telephone conference call with the Patient Participation Group
  • Telephone calls with care and nursing home who received a GP service from the practice.

Our findings

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we inspected
  • information from our ongoing monitoring of data about services and
  • information from the provider, patients, the public and other organisations.

We have rated this practice as Good overall and good for all population groups except Working age people (including those recently retired and students) families, children and young people and people with long term conditions, which we rated as Requires Improvement.

We found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
  • Not all patients received effective care and treatment that met their needs.
  • Clinical data for patients with long term conditions, families, children and young people and working age people was negative in some areas. The practice was aware of this and had developed recovery plans to review and manage these areas.

Whilst we found no breaches of regulations, the provider should:

  • Continue to develop the significant event process and root cause analysis.
  • Review and improve how carers are identified and recorded.
  • Continue to review the backlog for monitoring of patients who have long term conditions.
  • Improve engagement with those eligible for cervical cytology and cancer screening.
  • Continue to improve the uptake of childhood immunisations.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

11 February 2019

During a routine inspection

We carried out an announced comprehensive inspection at Carlton Group Practice on 11 February 2019. The announced inspection was part of our inspection programme.

We based our judgement of the quality of care at this service on a combination of:

  • What we found when we inspected
  • Information from our ongoing monitoring of data about services and
  • Information from the provider, patients, the public and other organisations

We have rated this practice as requires improvement overall.

We rated the practice as requires improvement for providing safe services because:

  • The practice did not have risk assessments in place in relation to medicines for use in the event of an emergency not held at the practice sites.
  • The practice had not ensured that both practice premises had appropriate documented health and safety and security risk assessments in place. However, an external company was employed to undertake these assessments on 15 February 2019.
  • The systems, processes and practice that helped to keep patients safe and safeguarded from abuse were insufficient. In particular that their safeguarding policies did not reflect current national updates. They had not implemented a system to monitor and follow up children who did not attend their appointment following referral to secondary care.
  • Infection Prevention and Control processes had not been adequately applied at the King Street site.
  • Staff had not been in receipt of all training appropriate for their role according to the practice’s policy and protocols.

We rated the practice as requires improvement for providing a caring service because:

  • Patients were less positive than the local CCG and England averages in being treated with care and concern and their confidence and trust in the healthcare professional they saw or spoke to.
  • Only 0.7% of registered patients were electronically coded as being a carer.

We rated the practice as requires improvement for providing a well led service because:

  • There were gaps in the practice’s governance systems and processes.
  • The practice had not shared or documented a sustainable practice business plan or strategy.
  • There was a lack of oversight on the maintenance of accurate records of skills, qualifications and training for staff and in staff appraisals.

We rated the practice as good for providing effective services because:

  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence-based guidelines.
  • The practice understood the needs of its population and tailored services in response to those needs. There was evidence of a number of projects and services the practice had been involved with to ensure patients’ needs were met.

We rated the practice as good for providing a responsive service because:

  • The practice had acted on the National GP survey findings and implemented a number of changes. These included a new telephone system, staffing reviews, various ways of making and cancelling appointments and appointment options such as shorter five-minute single problem appointments as well as normal appointments and telephone GP consultations.
  • The complaint policy and procedures were in line with recognised guidance, trend analysis and learning was derived from these incidents.

These areas affected all population groups, so we rated all population groups as good, with the exception of families, children and young people which was rated requires improvement in effective and therefore rated as requires improvement overall.

The areas where the provider must make improvements as they are in breach of regulations are:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
  • Ensure the proper and safe management of medicines in particular emergency medicines.
  • Ensure the practice premises have appropriate documented health and safety and security risk assessments in place.
  • Ensure there are effective systems, processes and practice that help to keep patients safe and safeguarded from abuse.
  • Ensure that persons providing care or treatment to service users have the qualifications, competence, skills and experience to do so safely.

The areas where the provider should make improvements are:

  • Implement safeguard policy updates in line with local and national guidance changes.
  • Develop the staff training matrix which enables clear oversight on all staff training.
  • Consider obtaining lockable metal cabinets for patient paper records security at the Carlton Street site.
  • Further develop the significant event system to include non-clinical staff at meetings.
  • Continue to improve the practice carer register numbers.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

13 October 2014

During a routine inspection

Letter from the Chief Inspector of General Practice

We inspected this service on 13 October 2014 as part of our new comprehensive inspection programme.

The overall rating for this service is good. We found the practice to be good in the safe, caring, effective, responsive and well-led domains. We found the practice provided good care to older people, people with long term conditions, families, children and young people, working age people, people in vulnerable groups and people experiencing poor mental health.

Our key findings were:

  • Performance was consistent over time and patients were kept safe because there were arrangements in place for staff to report and learn from incidents that occurred.
  • Patients received evidence based assessments and care and treatment was planned and delivered to promote a good quality of life
  • Staff treated patients with respect and kindness. Patients told us that staff were caring and compassionate. They said that they had confidence and trust in the GPs they saw or spoke with.
  • Services were planned and delivered to meet the needs of the patients. The practice was aware that improvements were needed to the appointments system to enable improved access for patients. Some changes have been made to the call back system for patients and this was being closely monitored
  • The leadership and management within the practice promoted an open and transparent culture. Staff felt supported and able to contribute to the running of the service. The practice sought and acted on feedback from staff and patients

An example of outstanding practice that we saw was:

  • The practice had implemented a new initiative in conjunction with the Clinical Commissioning Group (CCG) which involved employing and developing newly qualified nurses and nurses new to practice nursing. This was a proactive approach to begin to address the future skill gaps in the workforce in general practice.

We identified one area for improvement. The provider should:

  • Develop staff knowledge of the Mental Capacity Act 2005 in relation to their roles

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice