Archived: Whitestone 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

The information shared with us by the provider did not demonstrate that they could implement the changes required to ensure appropriate and effective governance and clinical oversight. This included the safe management of medicines and learning from incidents to reduce the likelihood of recurrence.

We assessed a total of 5 quality statements from this key question. We found there was an absence of evidence to demonstrate specific actions taken to address the issues identified at the last inspection. Policies and procedures reviewed were not updated to reflect any changes and provide clear guidance to staff and outline roles and responsibilities to keep patients safe. The information shared with us by the provider did not demonstrate that they could implement the changes required to ensure appropriate and effective governance and clinical oversight. This included the safe management of medicines and learning from incidents to reduce the likelihood of recurrence. Overall the provider was unable to demonstrate effective systems in place for identifying and managing incidents to support learning and improvement.

This service scored 25 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider told us that safety would be a top priority at the practice and any changes put in place following the review would be discussed at staff meetings, to ensure clinical issues and other incidents would be addressed. The action plan and evidence the provider shared with us was not detailed to demonstrate these planned changes.

The provider told us that processes for investigating, reporting and learning from incidents would be reviewed and updated this would include the procedures for staff to report incidents, near misses, safety events and complaints. However, the evidence they shared with us did not demonstrate how learning from incidents and complaints would result in change and improve the quality and safety of the service.

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.

The evidence the provider shared with us was not detailed to demonstrate the changes they planned to put in place.

During our inspection in January 2024, it was found that the provider did not have adequate arrangements to protect their most vulnerable patients. Clinical searches showed that alerts to raise awareness that a patient was at risk of harm were not available for all vulnerable patients and other members of their household. There was a lack of management and clinical oversight of the practice’s safeguarding procedures. A review of the practice children’s safeguarding register showed that the records had not been reconciled and the practice did not maintain an adult safeguarding register. We were unable to verify that the locum staff used to support the running of the practice had completed safeguarding training. We found that Disclosure and Barring Service (DBS) checks for 3 of 4 clinical staff were not available.

At this assessment, the provider told us they would undertake regular audits to ensure they maintained and monitored the safeguarding registers. The action plan they shared with us showed that the review, reconciliation and implementation of safeguarding registers would not be completed until September 2024. There was no evidence as to what action would be taken in the meantime to monitor risks. There were no details as to how staff would be updated on the proposed new processes and systems and updates to policies. We were unable to gain assurances of the oversight of safeguarding processes.

During our inspection in January 2024 we found that the practice did not hold any emergency medicines (with the exception of medicines for use in anaphylaxis). There were no risk assessments in place to explain the rationale for not stocking these medicines or any mitigating action if they were required. At the time of inspection, the practice nurse did not have basic clinical equipment to undertake any blood pressure checks.

At this assessment the provider told us that the provision and management of emergency medicines and equipment had been reviewed, checked and updated to ensure staff could respond to a medical emergency. However, evidence was not provided to confirm this.

At this assessment the provider stated that emergency protocols and procedures would be developed and regularly updated and easily accessible to staff.

However, there was no evidence provided to support what the provider had told us about the changes to the provision and management of emergency medicines. There were no details as to which emergency medicines would be available on site, no details of who would complete the daily checks of the medicines and equipment and no written policy had been provided.

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

At our inspection in January 2024 our review of Patient Group Directions (PGDs) and Patient Specific Directions (PSDs) found that they were not all signed and up to date. These are legal documents under which Qualified nurses and Healthcare Assistants (HCAs) can administer medicines and vaccinations. Records examined also showed that patients were administered vaccinations and medicines outside of the appropriate legal framework.

At this assessment we were told that the PGDs and PSDs had been updated and both the practice nurse and the HCA would be delivering medicines and vaccinations under PGDs and PSDs respectively. However, evidence was not provided to confirm this.

During our inspection in January 2024 our review of patient records identified cases where the Healthcare Assistant (HCA) was undertaking medicine reviews and diabetes reviews. There was no evidence of training or oversight of the HCA role in relation to medicine and long-term condition reviews. Evidence suggested that the HCA was acting outside of their scope of practice and records indicated a lack of clinical oversight.

Evidence provided following the remote assessment in July 2024 did not include updated directions or reference the providers plans to make changes to the oversight of work carried out by the HCA in order to ensure patient safety.

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.

At the assessment interview the provider told us that the systems and processes for medicine management, which included staff practices, monitoring of high risk medicines, audits and accountability would be reviewed and updated. However, the evidence shared with us did not provide assurances that effective systems and processes would be in place to improve clinical oversight.

During our inspection in January 2024 we identified issues with the management of patients prescribed high risk medicines, which require monitoring due to risks of serious side effects. For example, there were no safety alerts on patients records to identify those prescribed high-risk medicines.

At this assessment the systems the provider planned to put in place in relation to medicines were not effective in addressing the concerns identified. The proposed systems involved the practice manager conducting audits and then deciding what should be passed on to a pharmacist. There was over reliance on annual reviews to monitor patients prescribed high risk medicines. This would not ensure appropriate monitoring of patients prescribed high risk medicines and was not in line with national guidance.

There were no protocols or policies submitted which set out the process, roles and responsibilities, clinical oversight, call and recall of patients, or action to be taken if patients did not respond to appointment invites or failed to attend appointments. There was no rationale given by the provider on their decision for a practice manager with no clinical qualifications to be tasked with the responsibility for the management and monitoring of patients prescribed high risk medicines.