Mayflower Medical Practice

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 rated the key question of safe as requires improvement. Whilst leaders promoted a proactive and positive culture of safety based on openness and honesty, our assessment evidence did not demonstrate that this proactive and positive culture was always embedded into practice. This was because whilst systems and processes were in place to manage significant events, not all staff were aware of them, and staff feedback over time indicated that the processes for managing and responding to significant events were not always consistently followed. For example, concerns were raised with us, and we saw evidence that safety incidents relating to the management of medicines within the dispensary were not always raised, discussed or addressed.

Whilst the provider demonstrated a commitment to improving the way they involved people to manage risks this was not fully embedded into practice. Systems to manage infection, prevention and control, safe staffing and the management of medicines were not always followed. For example, some prescriptions were not signed before medicines were dispensed and handed out to patients.

The service worked to safeguard people from the risk of abuse and demonstrated a joined-up approach to safety that involved the person themselves, staff and other partners in their care. This included during referrals, admissions and discharge, and where people moved between services. Facilities, premises, equipment and technology were appropriately maintained.

Further detail is referenced under each quality statement.

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.

Systems and process were in place to manage significant events. Leaders described how they had put in place new arrangements to increase the reporting of significant events as reporting numbers were felt to be low. However, we found that not all staff were aware of the arrangements, and staff feedback indicated that the processes were not always consistently followed.

Nine significant events had been recorded in the last 12 months. Records showed the practice had investigated them and learning put in place. Staff described actions that had taken place following events. However, based on the evidence we gathered at the time of the assessment; the evidence did not demonstrate that all significant events had been recorded and that leaders did not always work effectively to make sure learning from them was maximised, revisited to monitor the effectiveness of learning and always shared with staff. There were some incidents we may have expected to see recorded on the significant event record that had not been, even though staff described action they had taken to address at the time. Examples included a misplaced key for the emergency medicines cupboard and fridges used to store medicines going out of the recommended temperature range. We were told contact had been made with the lead GP and practice manager as to how to raise a significant event, but their query had been ignored.

Records of ‘near misses’ in the dispensary were not available at our first site visit. On the second site visit, these were made available. There were large time gaps in the recording, and it was not clear from the records what follow-up of changes introduced had been carried out. Concern was raised that incidents, particularly the dispensing of medicines were not always recorded and discussed.

The service collaborated with healthcare partners to establish safe systems of care, including shared care when patients moved between services and from children to adult services.

The provider informed us they processed all test results within 48 hours with the lead GP overseeing them daily. After the assessment the provider submitted a practice-specific workload standards policy dated 16.7.24 which detailed the expected standards for both clinical and administrative staff to managing test results and clinical correspondence. However, clinicians raised concerns with us regarding the lack of clarity around the process when managing test results. As part of the assessment, we looked at the practice’s clinical systems to view the number of patient referrals and test results that were outstanding and required action. All referrals and test results had been actioned.

The provider was trialing the use of an external company to scan and code letters onto patients’ clinical records. They had a service level agreement in place which referenced General Data Protection Regulations and the need to ensure the reliability of the staff who had access to the data. At the time of the assessment, we did not see any evidence that the provider had gained permission from patients for their information to be shared with a 3rd party. After the assessment, the provider sent us verification they had received post-assessment from the Information Commissioners Office that this was not deemed to be necessary. They also sent us an amended data sharing agreement.

Patient feedback reported a delay and a disconnect in information received by secondary care to the practice and back to the patient. Delays were attributed to delays by secondary care.

Reception staff followed a care navigation template which they received training on as part of their induction to ensure they directed patients to the most appropriate service or services to meet their presenting needs.

Meetings were held where the needs of patients with more complex needs or those approaching the end of life could be discussed.

The service worked to safeguard people from the risk of abuse. This included working with partner agencies. There were systems and processes to respond when it was suspected that people may be subject to abuse or neglect.

Most staff had completed or were up to date with safeguarding training at a level that was appropriate to their roles and responsibilities. One nurse was overdue completing Safeguarding Children Level 3 and 1 GP had not completed Level 3 adult safeguarding. All but 2 members of staff had completed Mental Capacity Act, Chaperone and Learning Disabilities and Autism training. This included a new starter and 1 GP. Most staff had a clear understanding of safeguarding.

Alerts were added to the patient record system when a patient was subject to a safeguarding concern. A log of all safeguarding events was maintained. Safeguarding was discussed within the practice and learning shared. For example, a learning brief was shared with staff from a recent Child Safeguarding Practice Review that showed how learning from the review would be applied by practice staff. Safe recruitment procedures were in place to ensure staff were appropriate to work in the service.

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

Whilst the provider demonstrated a commitment to improving the way they involved people to manage risks the concerns identified during our assessment referenced throughout the report meant that the changes introduced to manage risk were not fully embedded into practice.

Patients were mostly advised on risks related to their condition and actions to take if their condition deteriorated. Staff could recognise a deteriorating patient and knew of action to take. All but 2 members of staff had completed sepsis training. Outstanding was 1 clinical and 1 non-clinical staff member.

The provider 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. After the assessment, the provider sent us information to show water temperature and fire checks were being completed at Finningley.

Emergency equipment was available, and the location known to staff. Oxygen cylinders and adult masks were stored together for use whilst paediatric masks were stored elsewhere. Anaphylaxis kits were not available in rooms where they may be needed but staff told us they could access them in the central location where the emergency medicines were stored.

All clinical staff had completed CPR and anaphylaxis training, and most staff had completed fire safety and fire warden training.

We observed both premises to be fit for use. All equipment known to the provider had been checked and calibrated. We found a small number of items stored in clinical room drawers and cupboards that were not calibrated. After the assessment, the provider sent us information to show the equipment was not due to be calibrated as was relatively new.

Based on feedback received, the service did not always make sure there were enough experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together.

The provider had recruited new staff to fill vacancies; however, there were also instances of staff departures and sickness-related absences, which impacted overall workforce availability. The provider had attempted to recruit a practice manager, but this had not worked out. A site-manager for Bawtry and Finningley was now in post and staff reported the benefit of this role. Staff reported that clinical roles were mostly sufficiently staffed; however, there were concerns about staff numbers and support for non-clinical roles.

The service had an induction program. However, we were provided with examples where staff, both clinical and non-clinical had commenced work with little or no induction.

There were gaps in management and support arrangements for staff, such as appraisal and supervision. The provision of supervision and appraisal varied depending on the role. For example, nurses received a good level of support and supervision from their supervisor. Beyond that, we were told supervision and appraisal was infrequent.

Staff were supported when requested to complete further training. We saw examples of this. The training matrix provided showed that records were kept for 26 different training sessions the provider deemed as mandatory. Of these the following had been completed: administration team 99%, reception team 97%, dispensary team 78% (1 starter was part way through training), nursing team 94% and GPs 88%.

The provider referred staff to Doncaster and Bassetlaw Occupational Health Department under Doncaster ICB's contract who assessed the need for staff vaccinations according to their role. Everyone who had direct contact with patients should be up to date with routine immunisations. This included reception staff and those who handle samples or need to clean up bodily fluids. Vaccination records were seen for staff. However, the record did not include a check that the staff member (if required in their role) had received the vaccination for Varicella (chickenpox).

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly. Some records showed the practice manager was the designated infection prevention, and control lead and some showed it to be the lead nurse. A poster displayed at Finningley showed the lead to be the nurse. The practice manager had received training to support them in this role, the lead nurse had not. After the assessment the provider informed us the lead nurse had applied to undertake additional training, but no date was confirmed for this.

Cleaning schedules were in place at both Bawtry and Finningley. Cleaning arrangements for Bawtry were managed by NHS Property Services and at Finningley by the provider. Risk assessments and audits were completed, and action plans were in place for both sites.

However, we saw risks identified had been raised but not always actioned. At Finningley, internal cleaning and waste collection frequency by the cleaning contractors and the lack of sanitary bins being available had been identified as a risk for a considerable amount of time. Whilst the premises were observed as being visibly clean it was noted that, at this site, cleaners did not attend daily but twice a week. It was noted on the action plan that staff could empty bins if desired. Bins had been emptied at the time of the site visit. After the assessment, the provider showed us a new daily cleaning proposal dated 28.2.25 to commence 1.3.25.

The COSHH arrangements for cleaning were not well managed. No sanitary bins were available for patients or staff on the ground floor. Consulting rooms at Finningley were carpeted. The provider told us they planned to replace these but had no planned date. We were told that staff at Finningley deep cleaned the carpets every 6 months.

At both sites, single-use items were found in treatment and consultation rooms that had passed their expiry date. For example, hypodermic needles, chlamydia swabs, multi collect specimen kit and wound dressings.

We identified one Sharps bin which was overfull.

All staff except for a new starter had what the provider referred to as Level 1 training in infection prevention and control. All staff assessed as requiring Level 2 training had completed this.

Staff did not always follow systems and processes to ensure that medicines were managed safely. As well as reviewing medicines optimisation, we looked in detail at the dispensary and dispensing arrangements at both sites.

Medicines were stored safely and securely with access restricted to authorised staff. However, some prescriptions were not signed before medicines were dispensed and handed out to patients. Concerns were recorded in meeting minutes made available to us about the dispensing arrangements.

A delivery service was in place to deliver prescriptions to housebound patients. However, there was no audit trail to confirm receipt of the dispensed medicines by the patient. Concerns were raised with us regarding the safety of the medicine delivery service. Multiple examples of incidents were provided. One significant event had been recorded.

Recording of fridge temperature records to ensure the safe storage of medicines was not always completed in accordance with national guidance. There were significant gaps in the room temperature records for the area where medicines were dispensed from. Staff told us there had been significant events relating to fridge temperatures and that action had been taken. However, no evidence was available or significant events recorded to demonstrate what action had been taken. The provider provided information after the assessment to show they had reviewed their processes and logged significant events where fridge temperatures had been identified as going out of the recommended range.

Emergency medicines were available at both sites and the location was known to staff. A small number of emergency medicines had recently expired at Bawtry.

Processes were in place to manage blank prescription stationery.

There was a process for requesting repeat medicines and evidence of medication reviews. Standard operating procedures were in place for each process in the dispensary. Appropriate systems were in place for the safe management of controlled drugs.

The practice monitored the prescribing of antibiotics to reduce the risk of antimicrobial resistance. Prescribing data reviewed as part of our assessment confirmed this. For example, the number of antimicrobials issued by the provider was lower than local and national averages. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.

Dispensary staff had received appropriate training and regular checks of their competency. There was a process for acting on safety alerts. Patient Group Directions (a written instruction for the administration of medicines to groups of patients not previously prescribed for) were in place and up to date. There was a named GP responsible for the dispensary and staff told us they were an active presence in the dispensary.

As part of our assessment, a series of patient clinical record searches were undertaken by a CQC GP specialist advisor. This included a review of the management of patients on a sample of medicines that require monitoring, as well as the review of prescribing, including effectiveness and quality of medication reviews and usage.

165 medicine reviews had been completed in the last 3 months. These were found to be satisfactory.

Monitoring of patients prescribed certain disease-modifying antirheumatic drug (DMARD), in this case - Methotrexate, Azathioprine and Leflunomide was satisfactory. DMARDs are a class of drugs indicated for the treatment of several inflammatory arthritides, including rheumatoid arthritis (RA), as well as for the management of other connective tissue diseases and some cancers.

55 patients were recorded with heart failure and prescribed Aldosterone Antagonist. Of those, 12 had not had the required monitoring. We looked in detail at 5 patient records. We found evidence of potential patient harm in all 5. The provider was advised to review all 12 patients. Aldosterone antagonists are medicines that block the action of aldosterone, a hormone produced by the adrenal glands.Aldosterone regulates sodium and potassium levels in the body, and by blocking its effects, these drugs help the kidneys excrete excess sodium and water, which can reduce blood pressure and relieve fluid retention associated with conditions like heart failure

21 patients were recorded as elderly and on oral nonsteroidal anti-inflammatory drugs NSAID over 65 years or antiplatelet over 75 years and no PPI (no declined or not tolerated). Monitoring was satisfactory for these patients. NSAIDs are a class of medicine used to reduce pain, inflammation and fever. Antiplatelet medicines reduce the stickiness of platelets, preventing them from clumping together to form blood clots and Proton pump inhibitors (PPIs) are a class of medicine used to reduce stomach acid production.

4 patients were recorded as prescribed the teratogenic medicine Topiramate. Whilst all patients were either on reliable long-acting reversible contraception, no longer on the medication or were at no risk of pregnancy the provider was advised to review all patients prescribed teratogenic medicines. This was to ensure appropriate management and record of information on the patient record such as the signing of the annual acknowledgement of risk form and pregnancy prevention plan if applicable. Teratogenic medicines have the potential to cause birth defects or developmental abnormalities in a foetus when taken during pregnancy.

During the assessment process, the provider took action to review those patients identified as at risk. A summary of their findings were provided to CQC after the assessment. The provider also took immediate action to close down the dispensary at Bawtry and move the full service to Finningley. This was always their plan, but they brought this forward to try and address some of the immediate concerns we identified.