Lytham Road 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

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

This is the first inspection for this service since its registration with CQC. This key question has been rated as requires improvement.

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

This service scored 56 (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 had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. The provider took concerns seriously and proactively made improvements to the service. Managers encouraged staff to raise concerns when things went wrong. During staff meetings, the whole team discussed and learnt from clinical issues. Staff felt there was an open culture, and that safety was a top priority. The provider had processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Learning from incidents and complaints resulted in changes that improved care for others.

The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

Referrals and test results were not always managed in a timely way as there were some issues with the oversight of incoming diagnostic results and workflow. We reviewed the outstanding workflow for the practice and found that the oldest report was dated from 6 weeks earlier; this was an abnormal serum folate report (a test for anaemia). There were also further reports for an abnormal anaemia test and an abnormal HbA1C (a test for diabetes control) from over 2 weeks earlier. There were also multiple abnormal reports outstanding from a week earlier; these included kidney function tests, liver function tests, full and blood counts. This demonstrated that the practice did not have an effective system in place for oversight of the outstanding reports in the global workflow inbox. This posed a risk of potential delays in acting on results. Following the inspection, the practice advised they had implemented a new system where results would be checked and cleared 3 times a week to ensure nothing had been missed.

There were systems in place for processing information relating to new patients. The service worked with other providers to deliver shared care and when patients moved between services. However, we saw cases where patients were not monitored according to recommended intervals for some high-risk medicines. Referrals and test results were not always managed in a timely way as there some issues with the oversight of incoming diagnostic results and workflow.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. The practice acted on concerns working in partnership with other organisations. However, they did not effectively maintain a list of vulnerable people due to the way in which their records were coded. The practice was unable to produce, when requested, an accurate list of vulnerable patients, such as homeless persons, veterans, children living in a household where a child was on a protection register, those at the end of their lives, those with Do not attempt cardio-pulmonary resuscitation (DNACPR) records in place, and carers. This appeared to be due to inconsistencies in how those factors were coded.

However, 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.

The service did not work well with people to understand and manage risks. They did not provide always care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Patients who were prescribed high risk medicines were not always monitored in line with recommendations and best practice. During the clinical searches we identified high numbers of cases where monitoring was not recorded. Some of these were due to problems downloading records from a computer system, but the practice had not documented they had been reviewed, and that it remained safe for patients to continue on these medicines. However, we also found that some patients had not had monitoring at all, yet the practice continued to prescribe these medicines. Following the inspection, the practice advised they had reviewed the patients identified as requiring monitoring and had downloaded many missing results, meaning the numbers had reduced significantly. They had also devised a new process whereby measures to encourage compliance with monitoring were implemented.

Emergency equipment was available and maintained, however the full recommended list of medicines was not present and there was no documented risk assessment or rationale as to why they were not present or not required.

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 practice told us parents of children who had not attended for childhood immunisations and people who had not attended for cancer screening, were followed up and further encouraged to attend.

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 had enough qualified, skilled and experienced staff, however they did not always make sure staff received effective support, supervision and development. Whilst staffing numbers and their retention was good, the practice did not have in place structured and documented formal supervision. Staff stated they were supported but this was ad hoc and informal. There was no formal framework or documentation for clinical supervision. There was no formal oversight or review of performance, such as dip sampling or documentation reviews, and therefore a lack of assurance of competence of staff.

The practice provided us with their recruitment policy. The policy was in line with the requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. However, records kept by the practice were missing some key evidence. We checked a sample of employed staff, and we found that the most recently recruited staff member had only 1 reference whilst the policy stated 2 must be sought. Another member of staff had been recruited a year before and the practice did not have a copy of their proof of identity nor their full employment history. There were also gaps in evidence for staff recruited 8 and 9 years previously. It was evident that steps were being taken to establish those records, but gaps remained, notably no evidence of ID for a salaried GP recruited in 2016. Following the inspection, the practice stated they would retrieve the evidence where it was possible to do so and they conducted a risk assessment for the missing evidence, which was not now possible to retrieve. Disclosure and Barring Service (DBS) checks and evidence of professional qualifications were held for all staff records we sampled. We also saw that the practice had carried out Right to Work checks for staff using a non-UK passport.

The practice manager told us new staff had an induction to the building, but other than the staff member who started in post the day before the inspection no induction records were documented or retained. Similarly, confidentiality agreements were not retained. The practice stated they would ensure these records were made and retained going forward.

The practice had an appraisal policy in place, which stated all employees should have an annual appraisal. However, the practice did not include GPs in the appraisal process even though they were employed by the practice and we saw that some appraisals were overdue. Following the inspection the practice stated they would ensure GPs were included and had plans to catch up on outstanding appraisals.

There were a range of clinical and non-clinical roles within the practice. We found that the majority of staff training was up to date, learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence.

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. People were not involved in planning. The provider did not have effective systems to manage and respond to safety alerts and historical safety information such as Medicines and Healthcare products Regulatory Agency (MHRA) alerts. It was not always evident that staff followed protocols to ensure they prescribed all medicines safely, and to ensure people received all recommended medicines reviews and monitoring.

We carried out a series of searches on the services clinical systems as part of this assessment.

We looked at people prescribed methotrexate, used to treat inflammatory conditions such as rheumatoid arthritis and psoriasis. Blood tests are required every 3 months for patients prescribed this medicine to ensure they are not causing toxicity or organ damage. We sampled 5 patients and found that 3 were overdue monitoring, and 2 others had their tests done but were not recorded within their records. 3 of the 5 sampled did not have the day of the week stated for when to take their medicine, which is recommended. Several other patients appeared to be overdue monitoring, but were not examined in detail. These were shared with the practice. Following the inspection the practice downloaded and recorded some results for those patients who did not have their results on record. This improved the number of those who showed up in searches as overdue. They also reviewed the overdue patients, sent invites to attend for monitoring and described a system they were to implement to encourage compliance such as reducing the length of prescriptions or taking other steps to ensure oversight of non-compliance.

We looked at people prescribed aldosterone antagonists, used to treat heart failure. Urea and electrolytes (UE) tests are required for patients prescribed these medicines to ensure they are not causing any kidney issues. We found 1 patient had not had a UE test since 2020 and another since 2022. There were also potentially another 26 patients in this category who appeared not to have monitoring recorded. Following the inspection, the practice stated they had issues with blood test records being downloaded which they had subsequently addressed, which had significantly reduced these numbers. They also said they had taken action regarding 2 patients with significantly overdue monitoring and used measures to encourage compliance as above.

We looked at people aged over 75 who were prescribed direct oral anticoagulants (DOACs), used to thin the blood to reduce clots. Various tests are required to ensure the medicines do not lead to bleeding and complications, particularly for persons over 75 who require closer scrutiny. We found that 2 patients were on these medicines where they were contraindicated. 86 further patients appeared not to have had the correct monitoring. Following the inspection, the practice stated they had downloaded results to the patient records and were reviewing all of the cases to ensure patients were safe.

We looked at people prescribed teratogenic medicines, which are used to treat various conditions, such as migraines, but can cause or raise the risk of a birth defect in a baby. Of the 2 records we looked at in detail, we found issues with both of them, as there was no pregnancy prevention plan in place and a lack of clarity regarding effective contraception. Following the inspection, the practice reviewed these patients and removed the prescription in 1 case.

We looked at people prescribed citalopram or escitalopram, which is used to treat depression. This medicine can affect the electrical impulses in the heart and so is not recommended for those with heart conditions. Lower doses are recommended for those over 65, and heart monitoring should be done annually. We found there to be a lack of awareness of this Medicines and Healthcare products Regulatory Agency (MHRA) alert, as none of the recommended checks or advice had been recorded or referred to for the 3 patients whose records we looked into.

Staff did not manage prescription stationery appropriately and securely. We saw that the processes used by the practice were not effective. For electronic prescriptions we saw they made a record of the prescription serial numbers that went into the printers, but the records showed these entered the printer a year before and had not been checked since. There was no way of knowing what prescriptions remained in the printer or if they might have been misappropriated. Furthermore, for handwritten pads historical records were not available and there was no record of how many pads should have been in the drawer, nor if any had gone missing. Following the inspection the practice devised a prescription safety process which dictated that prescriptions records would more accurately reflect which prescriptions were in issue and where they were located and these would be signed in and out each day. Furthermore, that similar records were kept for paper prescription pads.

The practice did not have a programme of regular clinical audits of prescribing that focused on improving care and treatment.

However, medicines including controlled drugs were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines, vaccines, and controlled drugs. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments.

Staff took steps to ensure they prescribed antibiotics appropriately to optimise care outcomes. Prescribing data reviewed as part of our assessment confirmed this. For example, the number of antimicrobials issued by the provider was similar or lower to local and national averages.