Carlton Surgery

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

At this assessment we found shortfalls in the provision of well-led care. This was because not all staff knew the vision and strategy of the practice. There was no information on the practice’s website to inform people of their vision, mission or goals and no evidence of staff training on equality, diversity and inclusion in the staff files. Roles and responsibilities were not in all cases clearly defined to ensure good governance. We found shortfalls in the oversight and running of the practice which was evident from the lack of policy review and updates, IPC audits, safeguarding, significant events and complaints records, up-to-date staff training and oversight of medicine alerts. During the site visit we found staff were unable to locate key documentation, some was sent to us following our site visit whilst other documentation was still not provided. There were no records of staff meetings over the previous year and staff could not tell us of any learning and improvement action plan discussed at any of the meetings. We found the systems to ensure the monitoring of people with long-term conditions and to ensure people received medicine reviews was not working effectively.

This service scored 46 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff we spoke to did not to know what the direction of the practice was and what they plan to achieve. There was nothing on the practice’s website to inform the public of their vision, mission, or goals. A mission statement was sent to us following our assessment. However, it was not fully tailored to the practice having another GP surgery name included in the statement.

There was no evidence of training on equality, diversity and inclusion seen in the staff files and staff could not demonstrate a clear understanding of these. Following our assessment, the practice sent us training certificates for equality and diversity for all staff. With the exception of three staff members, the training had been completed after our assessment. There were no meeting minutes to confirm that leaders shared and discussed the vision and strategy with staff.

The business manager worked two days a week and the practice manager worked full-time hours. They told us that together they shared oversight of the day to day running of the practice with overall oversight provided by the GP partners one of whom was the CQC registered manager. The business manager told us they looked after areas such as health and safety monitoring, training and policy reviews whilst the practice manager looked after other specific areas. However, we found oversight of these areas was not effective with no clear demarcation between the manager roles. Health and safety risk assessments were not available, policies shown to us in need of review, and gaps in staff training.

Following the assessment, we requested roles and responsibilities for each position in the practice. The job description of the practice manager showed they had the responsibilities of taking the minutes of all meetings and distributing to relevant personnel, monitoring and ensuring all actions were taken. However, meeting minutes had not been documented since May 2023. The job description of the reception manager was not provided.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The practice had a range of staff with different levels of experience. However, they did not always understand the roles and responsibilities and how to carry them out to ensure safety of both patients and the workforce. There was no clear distinction of responsibilities for each member of staff. For example, not all staff were clear about who was the infection prevention and control lead.

Our assessment identified that improvements were required in relation to the management of risks relating to: • Monitoring of patients with long term conditions. • Safety alerts. • Medicine reviews. • Test results and correspondence. • Safeguarding. • Infection prevention and control. • Health and safety monitoring. • Communication between leaders and staff. • Learning from incidents and complaints. • Staff induction, recruitment and training. • Staff immunisations. • Governance processes.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We were told significant events and complaints were discussed in meetings. However, staff told us meeting minutes had not been documented since May 2023. Therefore, it was unclear if significant events and complaints were used to drive improvement as this information was not available to all staff.

Staff training was not up-to-date and there was no record of staff minutes and clinical meetings. None of the staff could tell us of any learning and improvement action plan discussed at any of the meetings. The practice gathered feedback from patients through the NHS Friends and Family Test, the results of which were provided to us. We also saw feedback from patients relating to one GP partner. The practice did not provide evidence of how feedback was used to drive improvement.