Archived: Stone Cross 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 assessed a total of 5 quality statements from this key question. We have combined the scores for these areas with scores based on the rating from the last inspection, which was good. Our rating for this key question is Inadequate.

We found breaches of regulation for this key question and have told the provider to take action. Significant events were not well managed; the practice did not assure themselves of staff competency when prescribing medicines. Safeguarding systems were not underpinned by appropriate policy and procedures. Fire and water safety systems were up to date. The practice had an effective system for recording and acting on safety alerts.

This service scored 28 (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 well managed approach to learning from significant events. The lack of recording of events did not demonstrate that lessons were learnt to continually identify and embed good practice.

Feedback from staff included that they knew how to identify and report concerns, safety incidents and near misses. However, our review of practice records identified that not all significant events had been documents and necessary actions taken. Staff told us that they didn’t receive feedback about the learning or action taken from the significant events. They were informed at meetings that an event had occurred and been investigated but no details about the actions and outcomes was shared.

Leaders told us that significant events were discussed in meetings. We saw staff meeting minutes dated January and February 2024. These showed that significant events had occurred, and staff were informed of these but there was no further information recorded or separate audit trail to show how these had been managed. This meant that staff were not provided with sufficient information to learn from these events to prevent recurrence.

The practice did not have a policy and procedure for dealing with significant events. This meant the provider could not provide assurances that significant events were managed consistently, that staff had access to guidance on what constituted a significant event, that incidents raised were appropriately investigated taking into account all relevant information.

Significant events we reviewed didn’t identify who was responsible for outcomes or actions required. We found actions and lessons learned were not always identified. The provider was unable to evidence that outcomes were effectively communicated to staff to prevent recurrence.

We did not look at Safe systems, pathways and transitions during this assessment. There is no previous rating for the Safe key question so we cannot yet publish a score for this area.

The service had safeguarding systems, but they did not always ensure that they were supported with accurate information and regular review.

Staff were up to date with safeguarding training at the appropriate level for their role. However, they could not tell us who the safeguarding lead was in practice and what steps they would take to raise or act on concerns.

We were told by leaders that the practice had identified the need to have a clear embedded approach to safeguarding meetings for children alongside the regular multidisciplinary meetings. However, there was no evidence that this had been implemented.

There was a system to follow up on children who were not brought to their appointment, either at the practice or secondary care. However, policies were not in place to underpin the practice approach to safeguarding adults and children.

Following our site visit we requested safeguarding policies. The practice provided limited safeguarding information following the visit. This did not include the requested safeguarding policies for children and adults. On 2 April 2024 we received safeguarding documents following a further request for information. This contained a children’s safeguarding policy and a clinical commissioning group (Medway CCG) “Safeguarding Standard Operational Procedure for Adult and Children 2018-2020”. The provider did not submit evidence of a safeguarding adult policy.

We did not look at Involving people to manage risks during this assessment. There is no previous rating for the Safe key question so we cannot yet publish a score for this area.

The service had systems in place to detect and control potential risks in the care environment.

Staff responsible for monitoring fire safety and health and safety told us that both the main and branch surgery had health and safety risk assessments carried out. They told us that actions identified in these health and safety risk assessments had been completed.

During our assessment we observed the environment to be safe from visual hazards relating to health and safety and fire. For example, fire exits were clear and free of obstructions. We observed that health and safety risks were reviewed in line with the practice’s risk assessments.

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. Fire and electrical risks assessments were up to date.

The practice could not demonstrate they assured themselves of the competence of clinical staff and non-medical prescribers when prescribing medicines.

Staff told us there was no system to proactively monitor prescribing practices of non-medical prescribers to ensure decisions made were appropriate. However, staff told us that when concerns were raised about a staff member’s prescribing, the practice had conducted ad-hoc audits to monitor this.

Practice leaders told us they had established systems to carry out clinical supervision. However, the practice was unable to evidence this. The practice could not demonstrate they followed their own staffing requirements to ensure they had enough staff to provide services to patients. Practice leaders told us they had regular locum and salaried GPs to support clinical care. Following the assessment, the provider submitted staff rotas for the weeks beginning 26 February 2024, 4 March 2024, 11 March 2024 and 18 March 2024, a staffing policy and a staff dependency calculator. The calculator showed that the practice had assessed the service as requiring a minimum of 25 hours per day of GP consultancy to be safe and effective. However, staff rotas provided by the practice evidenced that staffing levels did not always reach the safe level identified by the practice. For example, on 28 February 2024, the GP numbers were reduced to 2 locum GPs for that day. On 5 and 6 March 2024, there were no GPs available at West Drive Surgery. On 7 March, there was 1 GP on duty for that day with no specified time. On 14 March, the practice had only one GP available at Stone Cross and no GP at West Drive. On 22 March 2024, there was 1 locum GP scheduled to work 4 hours in the morning (9am to 1pm) at West Drive Surgery. However, there was no GP scheduled to work the at the practice in the afternoon. Additionally, there was no GP scheduled to work at Stone Cross Surgery that day. This meant that on the dates set out above the practice failed to meet this minimum safe standard.

There was limited evidence to show how the practice assured the competence of staff employed in advanced clinical practice. There was no established policy to underpin the procedure for the supervision of non-medical prescribers. There was no system of supervision for locum and permanent clinical staff including GPs and nurses at the time of our assessment.

Recruitment checks on staff (including locum staff employed directly) were not always carried out in line with regulations. We found concerns with 4 of the 6 staff records we assessed. We found that references were not always in place for staff and the practice could not evidence that checks to ensure registration with professional bodies had been undertaken for relevant staff. One clinical staff member had no file on record and no evidence of recruitment checks. The provider could not evidence that this individual was safe to work in the practice.

We did not look at Infection prevention and control during this assessment. There is no previous rating for the Safe key question so we cannot yet publish a score for this area.

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

We did not receive any feedback from people who used the service about medicines. However, our clinical searches showed that risks to people’s health was not always discussed with them when new medicines were prescribed, and patients were not always involved in their medicine reviews.

Staff told us they felt confident managing the storage, administration and recording of medicines. Staff told us they followed protocols to ensure they prescribed all medicines safely, and ensured people received recommended medicines reviews and monitoring. However, our remote clinical searches carried out on 20 March 2024 did not support this.

Staff managed medicine stock safely and regularly checked the stock levels and expiry dates for all medicines, including emergency medicines, vaccines, and controlled drugs. However, the practice did not hold all emergency medicines recommended by national guidelines and risk assessments were not in place to determine the range of emergency medicines held. Follow the site visit the practice supplied a risk assessment had been completed on 15 March 2023.

Blank prescriptions were not always held securely. During our site visit we found 2 prescriptions that had been printed but were not signed and left on top of the printer in one of the clinical rooms. The member of staff at the time did not know about these prescriptions and had not printed them. These were given to the practice manager. No other unoccupied rooms contained blank prescriptions.

The provider had an effective system to manage and respond to safety alerts and medicine recalls. For example, Medicines and Healthcare products Regulatory Agency (MHRA) and National patient safety alerts were managed by the Lead pharmacist who undertook relevant searches and highlighted patients to the locum GP’s who may need to be reviewed or require medicine changes.

Patient group directions (PGDs) were authorised in line with national guidance. (PGDs are a legal framework that allows some registered health professionals to supply and/or administer specified medicines to a pre-defined group of patients, without them having to see a prescriber such as a doctor or nurse prescriber).

We found 39 uncollected prescriptions dated from May 2023 to January 2024. These included prescriptions for antibiotics, lotions or anti-depressants. There was no process for monitoring uncollected prescriptions to ensure patients had been provided with the medicines they required. The provider took action to review and resolve this concern on the day of the inspection.

Our remote clinical searches identified that not all patients received the necessary monitoring for prescribed medicines. For example, we reviewed 5 patients prescribed 2 or more courses of rescue steroids for acute exacerbation of Asthma. We found not all patients had received a follow up in line with national guidance.