Carlton Surgery

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

At the last inspection, the practice was rated requires improvement for providing safe services because the practice was not managing test results and non-urgent referrals in a timely way, recruitment checks were inconsistent, and clinicians were not clearly documenting their monitoring of high-risk medicines and safety alerts in the patient records. At this assessment we found further shortfalls in the provision of safe care. This was because we were not assured that the processes for reporting, investigating, and learning from significant events, safeguarding concerns and complaints were robust and that staff were able to access information regarding them as staff meeting minutes had not been documented since May 2023. Although the complaints procedure was on the practice’s website, people we spoke to said they did not know how to raise their concerns and there was no visible complaints procedure displayed in the practice. We found inconsistencies in recruitment, induction, staff training and immunisation records. During the site visit the practice could not provide an audit of infection prevention and control (IPC) and staff were unclear on which staff members were the IPC leads. The practice could not provide a fire risk assessment or health and safety risk assessment to demonstrate that the care environment was safe. Our clinical searches identified inconsistencies with the monitoring of people with long-term conditions such as asthma, diabetes and hypothyroidism and the review of people on medicines for pain relief and epilepsy. We identified that MHRA (Medicines & Healthcare products Regulatory Agency) alerts were not always acted on and we found blood test results and documents from 2023 that had not been filed.

This service scored 41 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Not all patients we spoke to knew how to make a complaint and who to complain to. There was information on the practice website but there was no visible complaints procedure displayed in the practice for those patients who were digitally excluded.

The business manager said they handled complaints or the practice manager, depending on the type of complaint. They said that 7 complaints had been received in the last 12 months, and all handled according to practice’s complaints policy without NHS England involvement. Staff said team meetings were not documented since May 2023 and there was no log of complaints, significant events, action taken and learning available. The practice manager said they did not know where to find incident reporting forms, as there was no proper handover when they took over from the previous manager in 2022. A GP partner said there hadn’t been any significant events for some time apart from one the day prior to our assessment which had not been written up yet. Following our assessment, the practice manager emailed us several complaint response letters and a significant event report. The report was a brief write up with learning points however it did not represent a thorough analysis. A GP partner said more needed to be done regarding recording of incidents as they had not been writing these up.

The managers showed us complaints and incident policies. The practice did not keep a log of complaints or significant events. There was no clear process for reporting, investigating and learning from significant events as they occur. The were no team meeting minutes available since May 2023, the practice could not demonstrate any discussions, action taken or learning from complaints and significant events. We did not see a complaints policy or protocol in the reception area for patients. The practice’s website had a link to the complaints policy and a webform for raising concerns.

One patient told us of an occasion when their prescriptions sent following hospital discharge went missing. The hospital was contacted to resend, and it was resolved although the patient had a long wait. A second patient told us that referrals were made to support their health needs and next steps were shared accordingly. There had been no delays with prescriptions and there had not been any changes to their medicines. A third patient told us they were satisfied with a hospital referral and a referral for bereavement support.

Staff understood their responsibilities to process routine referrals. Staff understood their responsibilities to manage urgent cancer referrals and follow these up to ensure patients had attended their appointments within the two-week period. Clinicians could not demonstrate the complete oversight of the monitoring of people with long-term conditions, people’s medicine reviews and The Medicines and Healthcare products Regulatory Agency (MHRA) alerts as identified from our clinical searches. Following the assessment, leaders provided some mitigating circumstances and told us they would make the required improvements to ensure effective oversight.

We did not receive any specific feedback from commissioners or other partners. We noted from Multi-Disciplinary Team meeting minutes evidence of discussions with other health and care professionals who work with the service to manage vulnerable people.

During the assessment, we found some shortfalls with the management of test results and correspondence. We identified 4 blood test results not filed and 8 letters not dealt with dating back to 2023. Following the assessment, the provider told us that the letters were an administration error, they had been sent to the nurses when they should have gone to the doctors and that blood reports not filed were usually due to the fact the patient is either not on their practice register or the result is incompatible with the practice’s clinical system in which case they are entered manually. We did not identify any harm done to patients in relation to these. There was a failsafe system for the processing of urgent cancer referrals and ensuring people attended their appointments within the two-week timeframe. We saw from Multi-Disciplinary Team meeting minutes dated 02/05/24 that the practice worked with other healthcare professionals such as the palliative care team, district nurse, community matron and social workers to manage complex patients.

Patients did not raise any concerns about safeguarding during the assessment. We have not received any safeguarding concerns directly to CQC in the last 12 months.

Staff could explain how safeguarding concerns were recognised and how they would be reported. A GP partner was the safeguarding lead who told us they did not keep a safeguarding log, but they do keep a note on the patient record. There was no evidence of safeguarding cases discussed because team meetings had not been documented since May 2023. Staff said the practice had not had any recent safeguarding concerns. Leaders said that staff had undertaken chaperone training however there was no training certificates available to confirm. Following the assessment, the practice emailed us the training certificates, some staff had completed the training prior to our assessment and some afterwards.

We did not receive any specific concerns from commissioners or other partners about safeguarding.

At the assessment, we found some staff had received Disclosure and Barring Service (DBS) checks before commencing work at the practice while others do not have copies of the DBS certificates on file. During the assessment, managers could not ascertain the status of the DBS certificates through the online update service (a government subscription service that all who work in care use to ensure that DBS certificates can be transferred form one employer to another, and all employers can check the status of each employees DBS). During the assessment, a staff member went to the website, but nothing was ascertained about the staff DBS status checked. We found gaps in staff training for safeguarding children and vulnerable adults. One staff member started completing the training during the site visit after we had requested for their training records. In addition, the safeguarding policies we were provided with were not up to date. The safeguarding children policy was last updated in 2012 and the safeguarding adults policy last updated in 2022.

People said they felt involved in their care and treatment. Care and treatment was explained to people in ways they could understand and were given options for their treatment, for example regarding referrals to other services. Results from the national GP patient survey showed that the practice was in line with England averages for being involved in decisions about care and treatment.

Staff said there were systems to schedule appointments for people with long-term conditions and for immunisations and screening. However, we identified patients during our clinical searches that did not have medicine reviews or monitoring of their conditions.

The practice had some arrangements to respond to medical emergencies. There were emergency medicines stored in the nurses room. However, we found two expired medicines in the emergency medicines bag. These had been replaced with new stock but left in the emergency bag which could have been used by mistake in the event of an emergency. These were taken out by the assessment team and given to the practice manager for safe disposal. We found gaps in basic life support training for staff, and we found that staff had not received training in recognising the signs and symptoms of sepsis, a life-threatening condition that requires immediate attention.

We found there was one entry and exit access for patient and visitors, however, staff confirmed that there is another access used only by staff. There was a fire exit sign on the wall above the main entrance. The entrance is not easily accessible for a patient who uses a wheelchair. Staff said they do not have many wheelchair users. Treatment rooms were available for use downstairs for GPs to attend to people who are unable to go up the stairs due to mobility issues.

We observed appropriate equipment in clinical rooms. There were a few issues such as some expired emergency medicines which had not been disposed of despite a replacement also in the same bag which could potentially cause harm if used in an emergency.

During the assessment, managers could not locate a fire risk assessment or a health and safety risk assessment. Therefore, we could not ascertain how these risks were managed. Following the assessment, the practice emailed these documents both undertaken in 2019 with no evidence of recent review. The practice held up to date documentation for the calibration of medical equipment and portable appliance testing. There was a contract in place for the servicing of fire safety equipment and fire drills were rehearsed annually. Medical oxygen and a defibrillator were stored appropriately and checked regularly to ensure they were in good working order. A staff member had undertaken fire marshal training however not all staff had fire safety training certificates in their files. Following the assessment, the practice emailed fire safety training certificates for all staff with some staff having undertaken the training after the assessment. The practice carried out regular water temperature checks to minimise the risks of Legionella bacteria.

A patient told us about a negative experience they had with getting their blood test result, new staff were at the front desk and seemed unsure of what the mix up was, but the staff was able to resolve the issue providing a favourable outcome.

The practice clinical team consisted of two GP partners, a salaried GP, an advanced nurse practitioner, a practice nurse and two health care assistants’s. The patient population was approximately 5,200 patients. The partners confirmed that the patient population was deprived with limited or no education, ill-chosen lifestyle choices, and the influx of immigrants housed in a hotel next to the practice whose first language was not English language had impacted on the pressure facing the practice. The GP partners also told us that one of the partners had been on sick leave for 3 months which had had an adverse impact.

During the assessment we checked seven staff files. We found gaps in the recruitment checks completed by the practice. These included missing references, DBS records, proof of ID, vaccination records and contracts of employment. Some of these were sent to us following the assessment and mitigation for some staff who had been employed for many years. However, there was no effective oversight to ensure all the documentation was in staff files. We found gaps in staff training in respect of safeguarding, basic life support, fire safety and infection prevention & control. Some staff training was undertaken following the assessment and the evidence sent to us which mitigated some of the risk. One staff member started completing online safeguarding and basic life support training during the assessment after we had requested for their training records. They told us the last face to face training for basic life support was in 2021. There was an induction process for new staff, however this did not include the collection of immunisation status information for both non-clinical and clinical staff. We raised this with the provider who informed us that they were now in the process of sorting this out. Some immunisation records were also sent to us following the assessment.

We did not collect the evidence to score this evidence category.

Staff were unsure who the IPC lead was and could not show us the IPC audit file. Staff could not confirm if they had been part of an IPC audit or if it had been discussed in any meeting. One GP partner told us they were the IPC lead and shared the responsibility with the nurse. The partner told us that they had undertaken the IPC audit with the nurse in 2023, but it could not be located on the assessment day. After the assessment we were told it had been missing for some time and would be redone.

We observed a sharps bin and a clinical waste bin in a clinical room. There was a waste contract in place and consignment notes seen. We observed the practice to be generally clean and there was a cleaner employed to clean the practice twice per week. We noted that the curtains in the clinical rooms were changed monthly. Soap dispensers and paper towels were available and there was a staff member responsible for ordering adequate supplies of Personal Protective Equipment. We were told that clinical staff cleaned clinical equipment but there was no cleaning log to verify this. There were no cleaning protocols available.

We found that details of the immunisation status of clinical and non-clinical staff were not kept and requested as part of the new starter checklist. This was raised with leaders at the practice who have said they will request this and action accordingly. Staff training records showed that the IPC training was not updated, with records showing 2018 and 2019 for some staff while other staff do not have any record of IPC training. There was no IPC audit available during the assessment and therefore we were not assured that IPC risks were monitored and mitigated sufficiently.

One patient told us there was a time when prescriptions sent from the hospital after discharge went missing. The hospital was contacted to send it again and it was resolved though the patient had a long wait.

At the last assessment, (August 2022) we found that the clinicians were not always recording the reasons for not having carried out blood tests for patients prescribed certain medicines (ACE inhibitors or angiotensin II which are medicines that affect blood pressure). At this assessment, we found inconsistencies with the monitoring of people with long-term conditions such as asthma, diabetes and hypothyroidism and the review of people on medicines for pain relief and epilepsy. We identified that MHRA (Medicines & Healthcare products Regulatory Agency) alerts were not always acted on. We shared our findings with the GP partners who said patients were sometimes not responsive when invited for reviews or requests for reviews were sent out. It was difficult to short script patients when they do not attend reviews as this has led to complaints in the past. The GP partners said they would now book in a review with patients during consultations to prevent missed reviews in the future. Staff told us there were established systems in place for ordering, storage, and administration of vaccines.

During the assessment, we saw medicines were managed and stored safely. There were no controlled drugs stored on the premises. Staff showed us how they monitored the stock levels and expiry dates for all medicines, including emergency medicines. We saw that vaccines were stored appropriately, and records were maintained to demonstrate the vaccines were stored within the correct temperature range. However, we found two expired medicines in the emergency medicines bag. These had been replaced with new stock but left in the emergency bag which could have been used by mistake in the event of an emergency. These were taken out by the assessment team and given to the practice manager for safe disposal. Patient Group Directions (PGD’s) were up to date and signed by nursing staff.

Our clinical searches identified inconsistencies with the monitoring of people with long-term conditions such as asthma, diabetes and hypothyroidism and the review of people on medicines for pain relief and epilepsy. We identified that Medicines & Healthcare products Regulatory Agency (MHRA) alerts were not always acted on. The systems in place were not always effective at identifying these patients.

Staff took steps to ensure antimicrobial medicines, such as antibiotics, were prescribed appropriately to optimise patient outcomes whilst reducing the risk of adverse events and antimicrobial resistance. Prescribing data reviewed as part of our assessment confirmed this, as the number of antimicrobials issued by the practice was lower than local and national averages.