Mill View 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.

At our last assessment, we rated this key question as Good. At this assessment, the rating has changed to Requires Improvement.

The service had established systems in place to support the delivery of safe care, however there were areas that required strengthening including learning from significant events, complaints and near miss events, recruitment and safe prescribing. Transparency needed to be improved with regards to fridge temperatures and displayed CQC ratings poster, and the service had restricted patient choice by not using electronic prescribing.

Staff did not always take steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. Antimicrobial Antibiotic prescribing was 7.2% higher than the England average.

The service was in breach of legal regulation in relation to regulation 12 safe care and treatment and regulation 17 good governance. We have asked the provider for an action plan in response to the concerns found at this assessment.

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 service did not always have a proactive and positive culture of safety based on openness and honesty. They did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

We reviewed significant events, and near miss events and found that although they were recorded and investigations had taken place, there was no clear evidence of investigation outcome and actions taken, along with dates completed.

We observed a CQC rating sign on a notice board which offered misleading information about previous ratings. There had been no formal complaints, and informal complaints were recorded in patient records, not on the complaints register as stated on the service website, so could not be reviewed for trends or outcomes. Complaints should not be included in patient records to avoid any future prejudice, to maintain patient confidentiality as only those involved should have access and due to data protection as patient’s records are for life whereas complaints have a retention record.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. There were systems in place for processing information relating to new patients. The service worked with other providers to deliver shared care and when patients moved between services. Referrals and test results were managed in a timely way.

The service 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 service shared concerns quickly and appropriately.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. The practice maintained a list of vulnerable adults and children and acted on concerns working in partnership with other organisations. Our review of the clinical system found that patients records contained safeguarding flags which included those residing in the same household.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Emergency equipment was available and maintained. Staff could recognise a deteriorating patient and knew of action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

The service detected and controlled potential risks in the care environment. They 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 checks had been undertaken and risks identified had been addressed. There was a business continuity plan in place which was monitored and reviewed. Signage showing opening times, appeared muddled and unclear.

The service did not always make sure there were enough qualified, skilled and experienced staff.

There were a range of clinical and non-clinical roles within the practice. We found training was up to date and the learning needs and development of staff was managed appropriately. However, we identified times when the service had been short staffed, and others had to work outside their training and competence levels to check work. On reviewing staff recruitment files, we identified safe recruitment practices were not always followed, for example, contracts of employment were not always signed by the employee, change of contracts were not always signed, and references were not always within a staff members file, and staff had not always had the appropriate immunisations for their role. The service shared further information after the site visit confirming these had been brought up to date.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The practice had a designated infection, prevention and control lead and all staff had had relevant training. External cleaners maintained a good standard of cleaning, and managed all equipment and products required for cleaning so only the basic necessities were kept in the building. Cleaning schedules were in place and followed.

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

Staff checked the stock levels and expiry dates for all medicines, including emergency medicines, vaccines and controlled drugs. Staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely. People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms. The provider had effective systems to manage and respond to safety alerts and medicine recalls.

We found that staff did not always follow protocols to ensure the safe dispensing of medicines. We reviewed the dispensary rota and noted on occasions, staff without the appropriate qualifications or training were involved in checking dispensed medicines, this increased the risk of error and was contrary to the practices policy.

On inspection we observed that the controlled drug records showed returned medicines had been issued to a patient after being returned from a previous patient, this is in contradiction to the practice’s Controlled drugs policy and could mean patients receiving medicines which have been inappropriately stored. On inspection we also saw medicines on the shelf which had the dispensing label removed. We could not be assured these had not left the practice and were not being reused following our findings with controlled drugs.

Fridge temperatures were not always recorded accurately. We observed discrepancies between printed temperature logs and raw data sheets for the same dates. In two instances, the record did not match, and one showed repeated maximum temperatures exceeding 8°C. This meant we could not be assured that the cold chain had been maintained for the safe storage of vaccines and other temperature-sensitive medicines.

Patients lacked choice in where they could obtain their prescriptions, as the service had turned off the electronic prescription service (EPS), the surgery had no agreement with the integrated care board to do this. However, staff told us that printed prescriptions were given to patients to take to another pharmacy if requested.

Remote clinical searches conducted by our GP specialist advisor indicated that the practice was mostly meeting prescribing standards. However, when we looked at patients on blood pressure medicines (ACE inhibitors or Angiotensin receptor blockers) to see if they had received the required monitoring. We identified that 31 out of 312 (10%) of patients on this medicine potentially required monitoring. All had had their blood pressure checked. However, of the 5 records sampled 2 patients had not been recalled for recent blood tests, 1 patient had a review but no blood test was done, 1 had refused a blood test. We understand after the remote inspection took place the surgery immediately recalled 2 to have the blood test done, and one had declined testing.

Staff did not always take steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. Prescribing data reviewed as part of our assessment confirmed this. For 2023/24 Public Health England introduced new data reporting around antimicrobial resistance (AMR) surveillance and monitoring. On reviewing the data, it highlighted in the most recent period (2024 Quarter 4) the percentage of broad-spectrum antibiotic items prescribed by the practice was 10.9%, which was above the 7.2% England average. In addition, the total number of prescribed antibiotics items per 1,000 registered patients for the practice was 184.3 which was above both the East Staffordshire PCN and England values, 145.0 and 121.9 respectively.