Upper Thames Medical - The Park Surgery and Lechlade Medical

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 assessed all quality statements in the safe key question. This is the first assessment of this service since its registration with CQC. At this assessment, we rated the key question as: Good. We found the practice had a good learning culture and people could raise concerns. The practice regularly reviewed, investigated and analysed, and learnt from events and incidents. When things went wrong staff took appropriate action to ensure people remained safe and safeguarded from abuse. The practice had systems for the appropriate and safe use of medicines and involved people when any changes occurred to their prescribed medicines. The facilities and equipment met the needs of people and were clean and well-maintained. There were enough staff with the right skills, qualifications and experience.

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 practice 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. The practice learned and made improvements when things went wrong. Representatives from the Patient Participation Group (PPG) commented the service took concerns seriously and proactively made improvements. Complaints were shared with the PPG who told us they felt the service was open, honest and transparent in the sharing of information. People felt supported to raise concerns and staff treated them with compassion and understanding. Managers encouraged staff to raise concerns when things went wrong, staff understood how to raise concerns and report incidents both internally and externally. Staff told us learning from events and incidents was shared in both clinical and non- clinical meetings with the wider staff teams. Staff told us leaders were approachable and promoted an open, non-blame culture. Policies and procedures supported and promoted a learning culture. Leaders demonstrated they managed significant events and complaints appropriately and staff were involved in identifying learning and making changes that improved the care and treatment for people and embedded good practice. There was a system to monitor incidents and complaints. This included undertaking an investigation into the cause and actions identified to address the concerns.

The practice worked with people and healthcare partners to establish and maintain safe systems of care in which safety was manged and monitored. Staff promoted the continuity of care, including when people moved between different services. Referrals to specialist services were documented, contained the required information and were prioritised for routine or urgent action. There was a system to monitor referrals and follow up on any delays. Partner organisations shared positive feedback with us about how the practice supported people living in local care homes, they told us they received weekly visits from the practice and people’s needs were responded to. Staff we spoke with shared examples of how they worked with other healthcare services to ensure people’s needs were met. There were systems for processing information relating to new patients. However, there was a backlog of new patient records dating back to the beginning of December 2024, waiting to be summarised. The practice was aware of this and had taken action to address these concerns.

The practice 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 practice shared concerns quickly and appropriately working in partnership with other organisations. Staff were trained to appropriate levels for their role and were able to identify vulnerable people. They were aware of the systems and processes to keep people safe and safeguarded from abuse. Staff felt confident in raising concerns. Staff knew who the safeguarding lead was and how to access them. We saw the practice had implemented policies and procedures which demonstrated partnership working with other agencies and local safeguarding teams. Electronic systems alerted clinical staff to any potential safeguarding concerns when accessing patients’ records. There were regular meetings and discussions between the practice and other health care professionals, such as social workers and health visitors to support and protect vulnerable adults and children from risk of harm. A GP at the practice was in the process of taking on the role of the safeguarding lead and being supported by the GP currently in this role. They had time allocated to review and discuss any safeguarding concerns as part of the learning, development and transition into the role.

There were systems and processes to assess, monitor and manage risks to patient safety. Appropriately trained staff carried out consultations and provided specific advice to people during telephone and face to face consultations. Staff informed people about risks, for example in relation to medicines, and documented this on their patient record. This ensured they had an opportunity for their views to be listened to. Staff were confident in the systems and processes to enable them to respond to a deteriorating patient. There were adequate systems to assess, monitor and manage risks to patient safety.

The practice had made reasonable adjustments when people found it hard to access services such as ground floor level rooms and step free access. Staff were aware of their responsibilities to ensure the environment was safe for people, including their role in responding to an emergency. Staff had completed appropriate safety training. For example, health and safety, fire safety and information governance. Equipment was fit for purpose and maintained to ensure it was in good working order. Clear signage around the building supported people and staff in the event of an emergency evacuation. There was a business continuity plan which was monitored and reviewed when necessary. Health and safety risk assessments had been carried out and appropriate actions taken. However, we found the practice had not completed regular health and safety audits. Following the on-site visit, the practice provided assurances that a schedule of health and safety audits had been developed. We found not all confidential patient records were stored securely, for example, in an unlocked filing cabinet and in staff pigeonholes in a staff area. We observed the layout of the reception and waiting room meant that staff would not be able to observe a deteriorating patient. The practice immediately addressed our concerns and provided us with evidence to demonstrate they had acted in relation to these concerns.

The practice ensured there were sufficient qualified, skilled, and experienced staff who received effective support, supervision, and opportunities for professional development. Staff collaborated effectively to deliver safe, person-centred care. Staff reported that staffing levels were adequate to avoid excessive working hours. However, a few staff noted a dependence on locum clinicians to fill clinical shifts. Leaders were aware of this issue and were actively recruiting an additional GP. Staff were given protected time to complete mandatory training. Recruitment systems and processes had been developed. However, we found one new staff members file did not contain references from previous employment. There was evidence references had been requested, but no evidence a risk assessment had been completed until these references were received. Following the on-site visit, the practice provided assurances that references had now been received. There was a process to record staff immunisations status in line with national guidance. However, we found there were gaps in some files in the monitoring of staff immunisations. The practice provided assurances following the on-site visit that staff had been requested to provide the missing data, and they had updated the recruitment process to include a request for staff vaccinations at the time of appointment. Staff had completed mandatory training; this was centrally monitored to ensure timely completion. An induction programme supported all newly appointed staff. Clinical staff were supported to meet the requirements of professional revalidation. There was a system to ensure triaging of requests for care and treatment was carried out by suitably qualified and trained staff and appointments allocated to appropriate clinicians. The practice had oversight of the work carried out by non-medical prescribers. For example, a review of a selection of clinical records had been completed and discussions followed regarding clinical decisions and prescribing.

Staff were aware of their infection prevention and control (IPC) responsibilities and who the IPC lead was should they need additional support. Staff raised IPC concerns in team meetings. Staff knew how to manage clinical waste and specimens. Cleaning schedules and audits were completed, and the premises were visually clean. Clinical waste was stored in a locked bin in the car park. However, this was not in a secure area or fastened down to prevent it from being removed or tampered with. The practice acted on this, and steps were being taken to improve the safety and security of the clinical waste bin. Personal Protective Equipment (PPE) was available to staff. Staff had received training on infection prevention and control. Policies and procedures were available to staff. An up-to-date infection prevention and control audit had been carried out. However, the actions following the audit, identified one action that did not have a date for completion. The practice provided evidence on the day of the on-site visit to show this was in progress. We also noted that one clinical trolley was damaged, making it unsuitable for effective cleaning. In some areas, carpets were taped due to wear, particularly in waiting rooms and corridors, and showed bubbling in the server room. Following the onsite visit, the practice provided assurances that a schedule of works was in place to address the concerns regarding the worn carpets.

The practice made sure medicines and treatments were safe and met people’s needs. Staff were aware of systems to identify people who required monitoring based on the medicines they were prescribed. Non-medical prescribers (healthcare professionals who had undergone additional training and could prescribe medicines but were not GPs) were able to discuss their prescribing each day with a GP. Staff carried out regular checks on emergency medicines and equipment. However, the practice was not able to evidence the considerations given to not stocking certain emergency medicines in line with national guidance. We also found the emergency medicines were not secured and accessible. The practice immediately addressed our concerns and provided us with evidence to demonstrate they had completed a risk assessment to address not stocking certain medicines. A tamper-proof security tag had been implemented to secure the medicines. Staff regularly checked the stock levels and expiry dates for all medicine We reviewed a sample of Patient Group Directions (PGDs) (a written instruction for the supply and/or administration of a named licensed medicine for a defined clinical condition by named registered health care professionals without them having to see a prescriber) and Patient Specific Directions (a written instruction from a doctor or other independent prescriber for a medicine to be supplied or administered to a named patient) and found these had been completed correctly in line with guidance. However, we identified that the PGDs associated with the most recent influenza vaccination campaign were out of date. The practice acknowledged this and assured us that immediate action would be taken. They confirmed that a full review of all PGDs would be undertaken to ensure they are current, appropriately authorised, and compliant with legal and clinical governance requirements.Medicines were stored securely and at appropriate temperatures. The practice had systems to manage and respond to safety alerts and medicine recalls. However, we found there was no formal log or documented process to record this information. The practice took immediate action upon these findings and implemented a system and process to monitor, log, and ensure consistent dissemination of updates going forward. The keys to printers that housed prescription stationery was accessible and not secure. Following our on-site visit, the practice provided assurance that keys were now stored in a secure key box located in a secure area. Our remote clinical searches identified shortfalls in patient monitoring on certain medicines. For example, we identified 20 out of 457 patients who were on a direct oral anticoagulant (DOAC) (medicine that prevents blood clots) had not received appropriate monitoring. We also found 26 out of 1552 people prescribed an ACE inhibitor or angiotensin II receptor blocker (a medicine used to lower blood pressure). We reviewed 5 of these records and found 3 patients were potentially overdue monitoring in line with guidance. We identified 9 people prescribed simvastatin (a medicines used to treat high cholesterol and triglyceride (fat) levels in blood). We reviewed 5 records and found 5 patients had not been provided with information regarding the risks associated with taking these medicines. 3 out of 5 patients had not received a review of their medicine. Following our remote clinical searches, the service provided evidence that they had reviewed, developed and strengthened their systems to ensure people received the appropriate monitoring or review.