The Hollies 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 our last assessment, we did not rate this key question as we only assessed 4 quality statements in the safe domain. In this assessment, we have rated the key question of safe as requires improvement.

The service was in breach of legal regulation in relation to safe care and treatment.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

In our last assessment in March 2024, we found there were challenges in the absence of senior leaders to ensure consistent staffing arrangements. It was unclear who held positions of responsibility due to high turnover and frequent change of staff in lead roles. In this assessment, we found there was an improvement in staff turnover and recruitment had been carried out for clinical and non-clinical roles. However, shortly after the assessment there was a change in staffing in a leadership role.

The service did not always have a proactive and positive culture of safety based on openness and honesty. From our review of the practices’ complaints log, we could not be assured they always listened to concerns about safety and investigated and reported safety events. Whilst we saw minutes from meetings that some complaints were discussed, the practices’ complaints log lacked detail, so we did not have adequate evidence that lessons were always learnt to continually identify and embed good practice.

The practice did not have effective systems and processes in place to manage and respond to safety alerts. During our clinical searches undertaken as part of the remote inspection, we reviewed Medicines and Healthcare Products Regulatory Agency (MHRA) alerts and found patients subject to safety alerts were not appropriately informed prior to continuing their treatment or medication. This put patients at a risk of harm.

There was a system to record and investigate significant events, and when things went wrong, staff apologised and gave people support. Learning from incidents resulted in changes that improved care for others.

We found staff were not always encouraged to raise concerns when things went wrong. Some staff members felt there wasn’t an open culture, but felt safety was a top priority.

The service worked well with people and most healthcare partners to establish and maintain safe systems of care. They made sure there was continuity of care, including when people moved between different services. They did not always manage or monitor people’s safety, for example, through safeguarding procedures.

There were systems in place for processing information relating to new patients. We found referrals and test results were managed in a timely way.

In our last assessment, we found safeguarding training was not completed for all staff members. We found the practice did not have updated records of children and adult safeguarding registers nor were there minutes of regular safeguarding meetings held. In this assessment, we found safeguarding training had been completed for all staff members. Safeguarding policies were in place and known to staff, and staff were able to identify who the safeguarding leads in the practice were. However, we reviewed the practices’ safeguarding register for both adults and children and found updates were not routinely made on patient records on both registers. The practice, at the time of the assessment, could not show evidence of meetings being held with external health professionals or relevant agencies to discuss safeguarding concerns, although there were minutes of safeguarding concerns being discussed internally.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive, and enabled people to do the things that mattered to them.

Emergency equipment was available and maintained. Staff could recognise a deteriorating patient and knew of action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Contracts were in place to ensure the premises were maintained. Health and safety risk assessments and audits had been undertaken and risks identified had been addressed. There was a business continuity plan in place which was monitored and reviewed.

The service could not demonstrate staff were qualified for their roles. They did not always make sure staff received effective support, supervision, and development. They did not work together well to provide safe care that met people’s individual needs.

We reviewed a sample of clinical and non-clinical recruitment files and saw mandatory documents, such as Disclosure and Barring Service (DBS) checks were stored and secured. We attempted to review staff training records and found there was a lack of evidence of training completed for most clinical and non-clinical staff. The practice told us that staff training had been completed on a previous database prior to moving to a new system. However, they were unable to provide evidence of historical training or that staff had received relevant training recorded on the current database. After the assessment, the practice provided evidence of some staff members completing their training.

Appraisals had been completed for non-clinical staff who have been working for the practice over a year. The practice informed us that nurses and healthcare assistants had received appraisals by the previous practice manager but could not ascertain if this was completed formally, nor were they able to ascertain what discussions took place. After the assessment, the practice provided us with evidence to show completed appraisals for clinical staff.

There was an absence of formal supervision for clinical staff. There was no evidence of consultation audits being completed for doctors, nurses, and pharmacists within the practice. After the assessment, the practice provided us with evidence of formal supervision taking place with clinical staff.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The practice had a designated infection prevention and control lead and all staff had had relevant training. Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks.

The service did not make sure that medicines and treatments were safe and met people’s needs, capacities, and preferences. From our remote clinical searches, we found the provider did not have effective systems to manage patients prescribed high-risk medicines and those living with long term conditions. Our clinical searches identified 266 patients prescribed angiotensin converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) who did not have the required monitoring. We examined 5 patients and found no evidence on the practices’ clinical database that the required monitoring was carried out for all 5 patients.

As part of our clinical searches, we reviewed a Medicines and Healthcare Products Regulatory Agency (MHRA) of Valproate, a teratogenic medicine that can potentially cause birth defects in a developing foetus, being prescribed to patients of childbearing age. We found no clear evidence that patients who were prescribed Valproate were aware of these risks to allow them to make informed decisions prior to commencing and continuing their treatment. Our clinical searches identified 14 patients prescribed clopidogrel with either omeprazole or esomeprazole, a drug combination that is advised by MHRA guidance to be avoided. We examined 5 patients and found only one out of five patients had documented patient advice about the drug combination.

Our clinical searches identified 166 patients with a potential missed diagnosis of chronic kidney disease stages 3, 4 or 5. We examined 5 patients and found there was no appropriate monitoring for all five patients that we reviewed. We identified 155 patients prescribed gabapentinoids who had not been reviewed appropriately in the last 12 months. We examined five patients in detail and found 4 out of 5 patients had not been reviewed appropriately in the last 12 months.

Our clinical searches examined patients who were suffering from long-term conditions such as asthma, chronic kidney disease and hypothyroidism. From our review, we found that patients with long-term conditions did not always receive monitoring in line with best practice guidance for the above-mentioned conditions.

The practice was unable to demonstrate the correct administering of Patient Group Directions (written instructions for the supply of administration of medicines to groups of patients who may not be individually identified before presentation for treatment). On the day of the assessment site visit, we found that all Patient Group Directions did not have local authorisation to demonstrate staff who had signed to work under the PGD were safe and competent to do so. We were informed, via email, that the practice completed this after we had left on the day of the site visit.

Staff managed prescription stationery appropriately and securely. Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. Prescribing data reviewed as part of our assessment confirmed this.

Medicines were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments. People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms.