The Care Quality Commission
  • Doctor
  • GP practice

Carlton Surgery

Overall: Requires improvement read more about inspection ratings

The Surgery, 112 Hounslow Road, Feltham, Middlesex, TW14 0AX (020) 8890 3930

Provided and run by:
Carlton Surgery

All Inspections

During an assessment under our new approach

Carlton Surgery is a GP practice which provides primary medical services to approximately 5,260 patients from its location in the London borough of Hounslow. The practice team consists of two GP partners, a salaried GP, an advanced nurse practitioner, a practice nurse, two healthcare assistants, practice manager, business manager, reception manager and a small team of receptionists. The practice is part of Feltham and Bedfont Primary Care Network. The practice is open 7am to 6.30pm, Monday, Tuesday, Thursday and Friday and 7am to 7pm Wednesday. For out of hours services people are directed to NHS 111 or 999 for an emergency. The GP practice is registered with the Care Quality Commission under the Health and Social Care Act 2008 to provide the following regulated activities: diagnostic and screening procedures, surgical procedures, maternity and midwifery services, treatment of disease disorder or injury and family planning. We inspected and rated this service under our previous methodology on 17 August 2022. The practice was rated good overall, and for the key questions effective, caring, responsive and well-led. Safe was rated as requires improvement with a breach of the legal regulations in relation to safe care and treatment. We carried out our on-site assessment on 5 June 2024. We assessed a total of 12 quality statements across safe and well-led quality statements. The scores for these areas have been combined with scores based on the key question ratings from the last inspection. At the assessment although we found some areas had been rectified in relation to the management of non-urgent referrals we found continuing issues with the management of test results and recruitment checks, and in addition further breaches of the legal regulations in relation to safe care and treatment and breaches of the legal regulations in relation to governance.

18 August 2022

During an inspection looking at part of the service

We carried out an announced focused inspection at Carlton Surgery from 17-19 August 2022. Overall, the practice is rated as good.

Safe - requires improvement

Effective - good

Caring - not inspected, rating of good carried forward from previous inspection

Responsive - not inspected, rating of good carried forward from previous inspection

Well-led - good

Following our previous inspection on 25 April 2016, the practice was rated good overall and for all key questions.

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

Why we carried out this inspection

We carried out this inspection in line with our inspection priorities. The inspection was focused and covered the following key questions:

Is the service safe?

Is the service effective?

Is the service well-led?

Additionally, we reviewed the accessibility of the service to patients.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

  • Conducting staff interviews using video conferencing.
  • Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
  • Reviewing patient records to identify issues and clarify actions taken by the provider.
  • Requesting evidence from the provider.
  • A short site visit.

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 found that:

  • The practice was not always providing care in a way that protected patients from avoidable harm. The practice was not managing test results and non-urgent referrals in a timely way. Recruitment checks were incomplete. Additionally, the clinicians were not clearly documenting their monitoring of higher risk medicines and safety alerts in the patient records.
  • Patients received effective care and treatment that met their needs.
  • 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.

We found a breach of regulations. The provider must:

  • Ensure care and treatment is provided in a safe way to patients.

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

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services

25 April 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Carlton Surgery on 25 April 2016. Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.

Most risks to patients were assessed and well managed.

Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.

  • Patients said they felt the practice offered an excellent service and staff were friendly, caring, approachable, understanding and treated them with dignity and respect.
  • Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider should make improvement are:

  • Conduct a formal risk assessment of window blinds installed with free hanging looped cords to ensure compliance with national guidance and safety alerts issued.
  • Review blank prescriptions tracking log to include allocated distribution.
  • Consider specialist fire and legionella risk review to assure that all potential hazards are identified and managed.
  • Maintain a record log of smoke alarm testing and of fire drills performed.
  • Review the risk assessment in place for not having an automated external defibrillator (AED) for use in a medical emergency.
  • Ensure that all staff attend basic life support training at annual intervals in accordance with national guidance.
  • Maintain a record log of when fabric privacy curtains are washed and carpets cleaned.
  • Ensure that all staff receive regular appraisals.
  • Review systems to identify carers in the practice to ensure they receive appropriate care and support.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice