Newport Pagnell Medical Centre

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

There was a proactive and positive culture of safety based on openness and honesty, in which concerns about safety were listened to, safety events were investigated and reported thoroughly in most cases, and lessons were learnt to identify and embed good practices. Medicines and treatments were safe and met people’s needs in most cases. During our assessment we identified some areas relating to medicines optimisation which required improvements. The practice responded positively to these issues and had commenced a programme of improvement activity.

This service scored 94 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff and leaders understood their duty to raise concerns and report incidents and near misses. Staff were involved in investigating significant events and complaints and identifying learning. Staff and leaders were able to share examples of incidents and complaints which had been investigated and actions identified. Learning from incidents and complaints were shared with staff and agreed actions followed up. Feedback from staff and leaders demonstrated that the practice had a culture of identifying incidents and complaints, learning and improvement. Staff told us they felt they were able to raise concerns and report when things went wrong.

People told us that they had opportunities to provide feedback and they knew how to make a complaint. The practice displayed feedback forms in the practice and people could submit feedback or make a complaint using the practice website. People told us they had enough time during their consultation and they felt involved in decisions about their care and treatment.

The practice had a significant events policy and a reporting form which was accessible to all staff members. The practice had a significant events lead responsible for supporting staff in identifying and reporting significant events. The practice followed their significant events policy and discussed events and incidents during team meetings and learning was shared with staff. The practice had a duty of candour policy and involved people when managing significant events and errors. The practice had a clear system in place to record and investigate complaints. From the sample of complaint records we reviewed, we found the practice responded to people’s complaints in a timely manner. The practice offered apologies to people, lessons were learnt from individual concerns and complaints and action was taken as a result to improve the quality of care.

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 practice had a medicines management matrix group which regularly met. This group was made up of GP leads, prescribing nurses and non-clinical quality team members. The practice employed a clinical pharmacist who was a member of their urgent care team and also managed minor illness, respiratory and cardiovascular clinics run by the practice. The practice also received support from clinical pharmacists provided by the local Integrated Care Board and Primary Care Network. People with asthma and diabetes were managed in accordance with national guidelines. The practice had systems in place to complete annual health reviews for people on health registers such as learning disabilities, palliative care and safeguarding, and these registers were reviewed on a regular basis. The practice had carried out an audit on patients receiving a high-risk medicine used to treat blood clots. This audit assessed the monitoring and review of these patients and had identified learning and action which included discussing the results with clinicians to improve the ongoing monitoring of these patients. The practice had carried out an audit on patients receiving direct oral anticoagulants (DOACs) to assess the type of medicines prescribed, the dosage prescribed and the frequency of monitoring and review of these patients. The practice had reviewed 139 patients and had identified recommendations for the continued monitoring and management of these patients. There were appropriate arrangements in place for the safe management, use and oversight of controlled drugs.

People told us that they were able to get an appointment for when they needed one and the process to order repeat medicines was easy to do and well managed. People told us they were appropriately involved in decisions about their medicine. The practice worked closely with a local residential care home and the care home manager told us that the practice was very responsive to meeting the needs and preferences of their residents. The home manager told us there were good systems in place to manage people’s medicines and the practice was responsive to requests when changes to people’s medicines was required.

The practice had documented protocols in place for the management of medicines including a protocol for handling high risk medicines. During our clinical searches we found structured medicine reviews were carried out. The practice has systems in place to monitor the appropriateness of non-medical prescribers and clinical supervision was in place. The practice had good systems in place for the safe and effective management of clinical correspondence. Accurate and up-to-date information about people’s medicines was available, particularly when they moved between health and care settings. The practice had systems and processes in place to effectively monitor and manage most patients receiving medicines which required monitoring and high risk medicines in most cases. However, during our clinical searches we identified some gaps in patient monitoring. The practice had systems in place to receive, review and act on safety alerts in most cases. However, during our searches we identified some cases where the practice had not taken the appropriate action for all patients in response to some Medicines and Healthcare products Regulatory Authority (MHRA) safety alerts. Shortly after our inspection, the practice submitted evidence to us confirming a review of all patients identified in our searches had commenced. The practice had up-to-date Patient Group Directions (PGDs) in place, however during our checks we found 10 PGDs had been signed by staff after the authorising manager had signed the PGD. This was not in line with national guidelines on the management of PGDs. Shortly after our inspection, the provider submitted evidence to us confirming all of the PGDs had now been reviewed and re-signed by the authorising manager. The practice had introduced a new process to ensure the PGDs would be checked and re-authorised by the manager following the appointment of new employees when applicable.

During our checks we found all medicines were stored securely throughout the main practice and branch site. Prescription paper was stored securely and the practice maintained a record of prescription paper serial numbers. The practice held appropriate emergency equipment and emergency medicines at the main practice and branch site. Emergency equipment and medicines were checked on a regular basis. Vaccines were ordered and stored in accordance with national guidelines and the practice has systems in place to monitor the temperature of vaccine fridges. The practice held appropriate medical products and consumables. However, during our checks at the branch site we found a box of alocotip pre-injection swabs had expired in November 2023. The practice took immediate action to destroy this product and replaced it during our inspection.

Staff and leaders told us they had systems and processes in place to support the safe prescribing of medicines. The clinical team worked closely with the clinical pharmacists from the local Primary Care Network. Staff and leaders met regularly to review their prescribing and management of patients receiving high risk medicines and medicines which require monitoring.