Emsworth Medical Practice

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

We looked for evidence people were protected from abuse and avoidable harm.

This is the first inspection for this service since its registration with CQC following its move to a new location. This key question has been rated as requires improvement.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service promoted a positive culture of safety, based on openness and honesty. Staff were encouraged to raise concerns, and the provider was able to demonstrate that learning from complaints and significant events was taking place. A review of a sample of complaints and significant event records showed these had been investigated in line with the service’s process, with actions recorded and shared with relevant staff to support learning and improvement. The service held meetings every 8 weeks to discuss significant events and learning opportunities. A sample of events reviewed on site demonstrated that the process for recording and reviewing significant events was being followed.

However, there was no formal system in place for staff to record or report day-to-day incidents and near misses, which differ from complaints or significant events. This meant there was a risk that opportunities for learning from smaller, day-to-day safety issues could be missed. The provider told us they planned to strengthen this process by introducing a more structured way for staff to log and review all incidents, helping to ensure continuous learning and improvement across the service.

Staff described informal mechanisms used to reflect on events and share learning across the team. When things went wrong, staff apologised and provided support to those affected, and the service was able to demonstrate how they applied the duty of candour.

A representative from the Patient Participation Group (PPG) told us the provider responded positively to feedback and made improvements to the service. In response to concerns about appointment length and access, the service worked with the PPG to deliver regular health education and community support sessions. These sessions aimed to help educate patients about their health conditions, enabling them to better understand and manage their care. This, in turn, could help patients feel more confident when seeing a GP, support more focused consultations, and potentially reduce appointment length.

The service and PPG organised 2 to 3 health talks each year on topics such as cardiopulmonary resuscitation (CPR), women’s health, urology, and cardiovascular health. Sessions were delivered by qualified professionals, including consultants, and were well received by attendees.

The service worked with people and healthcare partners to establish and maintain safe systems of care in which safety was effectively managed and monitored. They ensured continuity of care, including when people moved between different services. Systems were in place for processing information relating to new patient records. The service had recently implemented ‘GP2GP’ to support the electronic transfer of clinical care records. At the time of inspection, the service had not identified any issues or delays in receiving up-to-date information in relation to people’s previous clinical records.

The service worked with other providers to support shared care arrangements. Referrals and test results were managed in a timely way.

The local community health team highlighted occasional uncertainty about whether correspondence sent to the service had been received. They told us they plan to move onto the same clinical system as the service in November, which is intended to improve communication and information sharing.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately, and meetings were held with stakeholders to discuss vulnerable people. However, minutes of these meetings were not recorded. The service’s clinical system highlighted vulnerable people and those requiring safeguarding, and the service maintained a safeguarding risk register. Individual clinical records were used to document relevant information, and these records were kept up to date.

There were designated safeguarding leads including a deputy at the service, and all staff knew who they were and how to escalate concerns. All staff spoken to were aware of what constituted a safeguarding concern, how to report it, and how to identify safeguarding flags on the clinical system. However, not all staff, clinical or non-clinical, were up to date with safeguarding training, which was deemed mandatory by the service. Service leaders confirmed they would begin booking protected time for staff to complete any overdue mandatory training.

Staff told us they would like to see improvements in chaperone training, with a preference for it to be delivered face to face. Leaders were not aware of this preference at the time of inspection but told us this would be discussed at the next all-staff meeting. Some non-clinical staff carried out chaperone duties, and people were informed that a chaperone service was available.

The service had identified that not all staff required a Disclosure and Barring Service (DBS) check. For non-clinical chaperones without a current DBS, appropriate risk assessments were completed to ensure safeguards were in place. These included measures such as ensuring a clinician was always present during any chaperoned interaction and that the staff member was appropriately supervised.

The service was committed to safeguarding by actively following up with individuals who did not attend scheduled appointments. Staff re-invited people using their preferred communication method, such as text message, phone call, or letter. This ensured vulnerable individuals were not overlooked, reducing the risk of harm associated with missed care. By maintaining engagement and continuity of treatment, the service supported early identification of potential safeguarding concerns and promoted patient safety through timely intervention.

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. Staff could recognise when a person’s condition was deteriorating and responded appropriately. Emergency equipment was available in the service and maintained appropriately. People using the service were informed about potential risks and were advised on when and how to seek further support if their condition changed.

There were systems for sharing information with staff and other agencies, supporting the delivery of safe and effective care. The service monitored delays in referrals and had processes to track urgent cases. For example, audits were conducted to ensure urgent cancer referrals were being appropriately booked with secondary care providers. These are urgent referrals are used to investigate symptoms that may indicate cancer.

The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities, and technology supported the delivery of safe care. The service had an Environmental Health and Safety Risk Assessment Template in place, which leaders stated was completed annually. However, during our onsite visit, the service was unable to provide evidence of a recently completed risk assessment or any historic assessments, including records of actions taken following previous or current reviews.

The service did not have effective oversight of health and safety and fire safety arrangements. Legionella monitoring records had not been maintained, and the last documented test was completed in 2022. There was no evidence to demonstrate that regular flushing of infrequently used water outlets had been carried out or recorded. This creates a potential risk of Legionella contamination, which could compromise the safety of staff, patients, and visitors using the water supply.

A fire risk assessment was completed in October 2024, with several actions identified and due for completion by December 2024. At the time of inspection, not all actions had been completed. There were no records to show that in-house fire drills had taken place, and the service was unable to demonstrate that its evacuation policy was fully embedded. It was noted that a recent TARGET Day focusing on fire safety was cancelled by the external provider, and the service was still trying to organise a new date.

The service had CCTV operating in public areas. However, there was no signage to inform people of this. During our onsite visit, the service acted promptly to ensure appropriate signage was displayed to meet privacy and security standards.

On the first floor, there was no routine staff presence in the waiting area unless a GP left their consultation room to call the next person. This meant that deterioration in a person’s condition might only be identified between consultations. However, the service told us staff carried out regular walk-arounds of the waiting area and reported they had not previously experienced an incident where a person’s deterioration had gone unnoticed.

However, the service had a business continuity plan that had recently been reviewed, and an information governance policy with designated leads at the service for escalation. A business continuity plan in a plan that a service or organisation puts into place to ensure it can continue running safely and providing essential services if something unexpected should happen. It sets out clearly what could go wrong, how the service should respond, and how normal operations can be restored quickly and safely.

The service had recently completed evacuation chair training to ensure people using the service and staff could safely exit the building using the stairs in an emergency where the lift was not accessible.

The service was able to demonstrate the lifts had been regularly serviced and maintained by an external company to ensure safe operation. Portable Appliance Testing (PAT) was carried out routinely to check that electrical equipment was safe to use, and equipment calibration was completed to verify that devices were operating accurately and reliably. These processes supported the safe use of equipment within the service.

Although the service had enough staff members, we found some gaps in documentation in regard to recruitment, training and supervision. Leaders confirmed that staff were qualified, skilled, and experienced, and we verified this during our inspection process. However, the service did not always hold evidence that recruitment checks had been completed. Leaders assured us these checks were carried out prior to employment, but documentation to confirm this was not consistently available. Since our onsite visit, the service has advised their recruitment processes now include professional registration checks and has outlined how they ensure staff not directly employed by the service are suitably skilled and qualified, in line with an agreed process with the primary care network (PCN).

Not all staff members were up to date with their mandatory training. The roles with overdue training included both clinical and non-clinical staff and covered 19 different training subjects. Leaders confirmed they would start booking protected time for staff to complete any overdue mandatory training, and some mandatory face-to-face sessions, such as basic life support, were already scheduled in the training calendar.

Whilst we were informed several informal supervision methods were in place, including case-based discussions, group reflections, lunch-and-learn sessions, and educational talks delivered by external speakers, the service was unable to provide evidence of formal supervision, monitoring, or appraisal arrangements for clinical staff and non-medical prescribers. The service did not have a supervision policy in place, and no formal records were available for staff involved in the training practice accreditation, such as medical students and Foundation Year 2 (FY2) doctors. This presented a risk that staff could prescribe outside their scope of competency without appropriate oversight. This was fed back during our onsite visit, where leaders advised this would be introduced.

The service assessed and managed the risk of infection effectively. They identified and controlled the risk of infection spreading and shared concerns promptly with the appropriate agencies. The service had a designated infection prevention and control (IPC) lead.

Cleaning schedules, provided by the external cleaning contractor, were available and consistently followed. The contractor also conducted quarterly audits, with findings shared with the service. All seating and flooring in clinical areas were made from wipeable materials to maintain hygiene standards, and bodily fluid spillage kits were accessible to staff to support the safe management of contamination incidents. The service had an appropriate arrangement in place for the segregation and disposal of clinical waste.

Risk assessments and audits were completed regularly, with actions taken to mitigate identified risks. All clinical staff had up to date training in infection, prevention and control (IPC) and the IPC lead conducted regular hand hygiene audits while also introducing aseptic non-touch technique (ANNT) audits. Some non-clinical staff were not current with mandatory training as defined by the service. Service leaders confirmed they would begin booking protected time for staff to complete any overdue mandatory training.

During our on-site visit, personal protective equipment (PPE) was available and well stocked for staff to use. Handwash dispensers were full, and appropriate hand drying arrangements were in place. The service held staff immunisation records, and of the 5 staff files reviewed on site, all three clinical staff had documented immunisations.

The service did not always make sure medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

Out of 60 people with chronic kidney disease (CKD) stages 4 or 5, 18 patients were overdue for the required blood test monitoring. We then reviewed 5 of these 18 patient records. All 5 required blood test monitoring, and 3 also required up-to-date blood pressure monitoring, in line with National Institute for Health and Care Excellence (NICE) guidelines. Out of 585 people identified as requiring monitoring for hypothyroidism, 31 were overdue for blood test monitoring. We then reviewed 5 of these 31 patient records, and all 5 required blood test monitoring in line with National Institute for Health and Care Excellence (NICE) guidelines.

Out of 64 people prescribed Disease-Modifying Anti-Rheumatic Drugs (DMARDs), such as Methotrexate, 5 patients were overdue for blood test monitoring. We reviewed all 5 of these identified records. Each required blood test monitoring. Clinical records showed the service had contacted these patients within the last three months, and there was evidence that a prescriber had checked the records before issuing a new prescription. We noted the service had undertaken recalls for all five records reviewed. However, there was a lack of evidence of other proactive measures to encourage uptake of blood monitoring despite recent prescriptions.

Out of 2,091 people prescribed ACE inhibitors, which help manage blood pressure and protect kidney and heart function, 138 patients were identified as not having received the required monitoring. We reviewed records for 5 of these patients, and all 5 had not received the monitoring required in line with National Institute for Health and Care Excellence (NICE) guidelines.

We reviewed 5 records for people with diabetes, and they had up-to-date HbA1c test results, which is used to assess average blood sugar control over time. This search showed that people had been effectively monitored and reviewed. For people with asthma, we saw those prescribed oral steroids were reviewed within 48 hours, in line with NICE guidance. We also reviewed 5 people’s records to see if they had a medication review within the last 3 months. All records confirmed that they had. This showed that some areas of the services recall processes were working.

The service responded immediately by revising recall processes and carrying out a full review. All affected people were recalled for monitoring, and the service demonstrated appropriate follow-up for those who had not responded to earlier requests.

The service had a process in which specific teams were assigned responsibility for recalling people requiring condition-related monitoring, based on their birthday month. This process was intended to enable proactive booking of appointments or the creation of tasks within other teams as a safety-netting measure. However, the remote clinical searches demonstrated that the process had not been working effectively, and feedback was provided to the service leads to improve its implementation.

There was a documented process for managing prescription stationery, but it was not being implemented as intended, posing a risk to effective governance and security. For example, prescription pads were returned to storage without serial numbers being recorded, meaning the service could not maintain an accurate audit trail. The emergency medicines bag was tagged with numbered seals, but there was no record of the tag numbers or evidence of regular checks or audits. As a result, the service could not demonstrate when the bag had last been opened or re-sealed. This means there is a potential risk that emergency medicines could be missing, expired, or tampered with, which could impact patient safety in an urgent situation.

However, medicines were stored securely and at appropriate temperatures. Staff routinely checked stock levels and expiry dates, including for emergency medicines and vaccines. Medical gases such as oxygen were stored safely, with appropriate risk assessments completed. Fridge temperatures were monitored daily, and there was a clear process in place to manage any temperature breaches. Temperature checks were consistently documented, and staff were aware of the procedure to follow should readings fall outside the recommended range.

All Patient Group Directions (PGDs) and Patient Specific Directions (PSDs) were in place and up to date. PGDs allow authorised staff to supply or administer specified medicines to a group of patients without individual prescriptions, while PSDs are written instructions from a prescriber for administering medicines to a named patient. The service-maintained oversight of both types of directives to ensure safe and appropriate administration. Staff demonstrated safe and appropriate prescribing practices, including for antimicrobial stewardship. Prescribing data showed the service issued fewer antibiotics than the national average, indicating responsible prescribing in line with national guidance.