Evergreen Practice

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• 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

During the assessment we reviewed policies, spoke with staff, and undertook observations while on site. We found the following: • There was a process to manage medicines safety alerts from the Medicines and Healthcare products Regulatory Agency (MHRA), however, the process did not include repeat searches to continually identify patients affected by an alert. • The culture was to learn from incidents; however, we were not assured significant event processes were sufficiently embedded to ensure they were effective. • There were clear processes for monitoring the stock of emergency medicines and equipment and our observations confirmed these processes were followed. However, the decision not to stock an item of emergency medicine had not been risk assessed. • The practice had a system to allow people to speak up when they had concerns and staff we spoke with told us they would be confident to do so and that action would be taken.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We found staff referred to significant events as learning events. Although staff told us they would be comfortable to raise an incident, not all staff were confident about how they would raise an incident, however they assured us they would seek guidance from a manager. We reviewed the log used to record incidents and found 4 incidents had been recorded in the last 12 months. As the number of recorded incidents was relatively low, we asked leaders whether the process was fully embedded in the practice, and they assured us the log was accurate and events were communicated throughout the practice. All staff except for 1 were able to provide examples of incidents and changes that had resulted from the investigation which confirmed information was shared. Our review of evidence identified concerns about the management of medicines safety alerts from the Medicines and Healthcare products Regulatory Agency (MHRA) and our remote clinical searches identified a group of patients that had only been advised of the risks associated with their prescribed medicines in the week prior to our assessment. We therefore spoke with the clinical lead and management to confirm the process for responding to safety alerts. We confirmed there was a process to receive, record and disseminate safety alerts to staff and, the clinical lead, supported by the clinical pharmacist, responded to alerts when received. However, the practice did not routinely repeat a search to identify any newly affected patients. Staff we spoke with told us they were encouraged and supported to raise concerns and would be confident to do so. Leadership and management spoke of how they would support staff to raise and address concerns but also wanted to empower staff to be more confident in responding themselves in the first instance.

The practice had a policy to manage the significant event process, a log to record events and we saw evidence that incidents were discussed at practice meetings. However, the meeting minutes provided limited information, the event log also gave leadership limited oversight of the process and the investigation report we reviewed did not demonstrate the practice had determined whether the incident was likely to be repeated. These findings meant we were not assured the process was completely effective. The practice had a system to manage medicines safety alerts from the Medicines and Healthcare products Regulatory Agency (MHRA) which included a policy, a log to record alerts when received by identified leads to review and respond. However, while the log recorded the alerts received, it provided limited detail about the action taken in response to review any patients affected. Our remote GP Specialist Advisor (SpA) completed remote searches of the practice’s clinical system which included reviewing the management of an alert related to medicines which may cause birth defects if they are used during pregnancy. The search identified 24 patients of child-bearing age taking these medicines and we reviewed a sample of 5 patients’ records. We found 1 patient had been informed of the risk before our assessment and 4 had been informed within the week prior to our searches. We found no evidence of any harm caused but were not assured the practice had an effective system to run repeated searches to identify patients affected by MHRA safety alerts. We reviewed the whistleblowing policy which included an external Freedom to Speak Up Guardian should staff want to raise concerns to someone outside of the practice. We also reviewed the Duty of Candour policy which documented a clear process of how the provider would comply with the process.

We asked the provider to place a link on their website to the Give Feedback on Care process so we could hear of patients’ experiences of care. This was published on the website, and we received 24 pieces of feedback during the assessment period. However, the feedback given did not relate to this quality statement. We also spoke with a member of the Patient Participation Group (PPG) and they raised no concerns about their experience of care at the practice. We reviewed the results of the GP Patient Survey and found the percentage of respondents to the GP patient survey who stated that during their last GP appointment they had confidence and trust in the healthcare professional they saw or spoke to was 91% compared to a national average of 93%.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe and effective staffing during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

The remote clinical searches completed by our GP Specialist Advisor found the practice had completed 413 medicines reviews in the last 3 months. We reviewed a sample of 5 medicines reviews and found no concerns for 4 of the 5 records sampled. 1 review did not include details of what had been discussed and reviewed, it only included a code to confirm it had been completed. However, we found evidence of good practice because 2 patients had received more than 1 medicine review in the last 12 months to support them to optimise their health.

During the assessment we interviewed staff remotely. We found examples of staff in specialist roles who had completed advanced training, for example in diabetes, and they explained how this allowed them to take a holistic view of the patient’s entire health when advising the GP of required changes to the patients prescribing.

The management of the cold chain included clear processes which involved twice daily checks and recording. A member of the nursing team was responsible for monitoring temperatures and was supported by the administration team should the nurse be absent from the practice. There were clear processes to monitor the expiration dates for emergency medicines and equipment and we found these operating as the practice intended, with no items out of date. The results of our remote clinical searches meant we were not assured the practice had effective processes to manage safety alerts from the Medicines Healthcare products and Regulatory Agency (MHRA). For example, our remote searches identified 24 patients of childbearing being prescribed teratogenic drugs. Our review of 5 patients found 4 patients had only been informed of the risk within the last week. After the onsite visit, the practice reviewed all the patients identified by the searches and confirmed all the patients been informed of this risk. Our remote clinical searches also indicated 21 of 61 patients prescribed gabapentinoids had potentially not been reviewed in the last 12 months. Gabapentinioids are used to treat neuropathic pain and occasionally to treat epilepsy. They are Schedule 3 controlled drugs due to the risk of misuse and abuse. Our GP Specialist advisor reviewed a sample of 5 patients and found 3 had been reviewed but 2 had not. Because we found evidence that 3 of the patients identified by our remote clinical searches had been reviewed we were not assured patients' records of care and treatment contained complete information and this indicated opportunities to improve record keeping existed. For example, by coding the type of medicine review completed.

We asked the provider to place a link on their website to our Give Feedback on Care process so we could hear of patients’ experiences of care. The practice published this on their website, and we received 24 pieces of feedback. However, this did not relate to this quality statement. We spoke with a member of the Patient Participation Group (PPG) and they reported the prescription request process worked well when they had used it.

While on site we reviewed the cold chain processes and found the recording of temperatures were well documented. We also found the vaccine fridge was clean and not overfull. We sampled a number of medicines in the vaccine fridge, and all were in date and we observed that the fridge was locked when not in use, with the key stored securely. We reviewed the emergency medicines and equipment held by the practice and found the emergency medicines were stored securely in the nurses’ room and emergency medical equipment was stored elsewhere in the practice. We found equipment and medicines were monitored to ensure expiration dates did not expire. Our observations found the practice did not stock medicine used to reverse the effects of opiates. We also found that although a defibrillator was kept on site, the practice did not have pads suitable for children under the age of 8 years old. We asked the practice whether these decisions had been risked assessed and they had not been. After the site visit the practice confirmed the defibrillator on site could be used for children under the age of 8 years old and requested a new, specifically suitable device from the management company. We found prescription stationary was stored securely when not in use. We also sampled the practices documentation for Patient Group Directions (PGDs) and Patient Specific Directions (PSDs). PGDs are a written instruction for the supply and administration of a licensed medicine to a group of patients. They are authorised by a qualified prescriber such as a doctor and are followed by non-prescribers. PSDs are an instruction to administer medicines to a list of individually named patients where each patient has been assessed individually by the authorised prescriber, but where the clinician administering the medicine is a non-qualified prescriber. We reviewed 7 PGDs and found 4 had not been correctly authorised because the clinician signed the document after the authorising prescriber.