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