Abbeyview 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. We found a breach in regulation under safe care and treatment and as a result took enforcement action asking the practice to take appropriate actions within 3 months to meet the areas of improvement identified. We found all emergency medicines were not always available and where risk assessments were in place these did not give sufficient information around mitigation in place. We also found patients at risk of lack of appropriate monitoring and review of medicines, and poor management of blood pressure readings.

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.

The service did not always have a proactive and positive culture based on openness and honesty. We saw examples that significant events were not always documented when being discussed in meetings. Not all significant events were thoroughly investigated and we did not see that lessons were always learned. Themes were not identified and reviewed for improvements. Complaints management was inconsistent. Complaints were responded to but the practice did not follow their policy; they did not acknowledge and respond to complaints within an appropriate timeframe. We saw an example where consent could not be evidenced when a complaint was raised on someone else’s behalf. Significant events and complaints were an agenda item on recent meetings but what was discussed was inconsistent, with no identification of themes and lessons learnt.

The service worked with people and healthcare partners to establish and maintain safe systems of care. An audit was carried out to check that 2 week wait referrals were being managed appropriately. Care homes served by the practice reported an overall good relationship, however, found communication was sometimes difficult with the practice. Clinical triage was carried out by appropriately trained staff to assess the urgency of care needed. Routine and follow up appointments were available within a reasonable time frame. All clinical tasks on the practice’s clinical system were up to date, however, some administration tasks needed actioning; these did not have a direct effect on patient safety. The practice has recently adopted an online triage system and were working to adapt this to ensure it functioned as expected.

The service shared concerns appropriately. Safeguarding policies were in place and known to staff. We were not provided with evidence that all staff had completed the necessary safeguarding training but were told records needed updated. Staff told us they had completed safeguarding training online. The practice had a safeguarding lead in place and regular meetings with the local health visitor were conducted. Alerts on patient notes relating to vulnerable children and adults were in place. Safeguarding was discussed in staff meetings to ensure the whole team were aware of recent developments.

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

Individual risks were not always adequately assessed and people were not always appropriately involved in this. For example, medication reviews were not comprehensive and individuals with long term conditions did not always have regular reviews. We therefore cannot be assured that people were always provided with information about how to keep themselves safe. Since our visit, the practice have provided evidence of clinical staff beginning to review all medicines which require monitoring, long term conditions and medicines reviews. Despite this, we are unable to assess the long term impact of this and maintenance of this system at this time. Our clinical searches found service user blood pressure recordings were altered and backdated and appropriate actions were not always taken following high blood pressure results. Therefore, we were not assured at the level of accuracy of these records.

Emergency equipment was available and most items stocked. For an item not stocked, there was a risk assessment in place, however, we found the risk assessments did not sufficiently mitigate risks. The practice reviewed this after our findings. Tamper proof seals were not in place for relevant medicines and there was no record kept of this. We did not see evidence that staff had undertaken training on managing the deteriorating patient but we were told records needed updating.

The practice did not always detect and control potential risks in the care environment. The premises was owned by NHS Property Services and they were responsible for maintenance of the building. Despite this, the practice lacked oversight of what was being carried out and actions were not all completed from outstanding risk assessments and actions relating to the area of the building they provided services from. A risk log was in place but was not well maintained. There was no external signage indicating the name of the practice. This meant people not familiar with the building could find it difficult to find the practice. The practice was limited by space and was awaiting a portacabin delivery to allow for much needed additional capacity. The waste area was not secure. The practice took some immediate steps to address these concerns raised following our on site visit.

Staff and patients told us there was a high turnover of staff at the practice. Patients told us they felt there were a lack of GPs and as a result, accessibility to appointments remained an issue. Leaders told us recruitment was a priority and they were working to address gaps within their staffing, however, we could not assess the long term impact of this. We received feedback from staff regarding high workloads and some staff told us they were not given a break during the working day. Staff did not always feel valued and did not always feel that concerns they raised would always be listened to or acted upon. We received positive feedback about a recent management change which made staff hopeful for the future but it was too early to assess the impact of this long term. We did not see evidence of formal supervision taking place. Staff told us they were allowed to attend relevant courses. We found an inconsistent approach to ensuring safe recruitment of staff. We saw evidence of staff files we sampled lacking required documentation to ensure staff were safe to work. The practice told us they were looking at addressing this.

The practice was visibly clean. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading. The practice had a designated infection, prevention and control lead and staff had relevant training. A 3-month cleaning audit had been implemented recently so it was not possible to assess the long term impact of this. Other relevant audits were completed and acted upon. We saw evidence of daily cleaning schedules.

Medicines, including controlled drugs (medicines requiring additional security measures due to their potential for misuse), were stored safely and securely. Staff regularly carried out checks for all medicines stocks and expiry dates for all medicines, but we found gaps in monitoring of room and fridge temperatures where medicines were stored. Blank prescriptions were not stored securely, as there were no robust audit processes to safely manage them. This meant there was a risk of misuse or diversion of prescription forms.

We saw that staff had the appropriate authorisations to administer medicines under a Patient Group Direction (PGD) or a Patient Specific Directions (PSDs).

We spoke to one non-medical prescriber who told us that they were able to discuss cases with a GP. However, there were no formal processes to record clinical supervision or audit the effectiveness of consultations and prescriptions.

The practice had systems to manage and respond to safety alerts and medicine recalls.

As part of our assessment, a Care Quality Commission GP specialist advisor (SpA) conducted a series of remote clinical searches of patient records. Our searches found that 60% of patients with polypharmacy (on more than 5 medicines) had not had a medicines review in 18 months. A plan was in place to recruit additional staff to support with this. A further review of medical records for nine patients with heart failure found that whilst all had a coded entry indicating a medicines review had taken place, five records lacked sufficient detail to confirm that a comprehensive review had occurred.

The searches also highlighted that some patients with long-term conditions continued to receive repeat prescriptions despite not attending medicine reviews. For instance, patients prescribed certain high-risk medicines, which require regular blood test monitoring, did not always have the necessary monitoring. These medicines continued to be prescribed, increasing the potential risk of harm due to insufficient clinical oversight.

Furthermore, 25% of patients prescribed medicines which can increase the risk of bleeding were not prescribed gastric protection. This placed them at harm of gastrointestinal bleeding.

Additionally, some patients who had received treatment for multiple asthma exacerbations over the past year had not received a review to optimise their treatment.