The Warren 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 looked for evidence that people were protected from abuse and avoidable harm. At our last assessment in December 2017, we rated this key question as good. At this assessment, the rating has changed from good to requires improvement. The service was in breach of legal regulation in relation to safe care and treatment. We found issues related to safeguarding, safe environments, emergency medicines and emergency equipment. We found that some required items were not available for use in the event of a medical emergency.

This service scored 53 (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 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. Lessons were learnt to continually identify and embed good practice. People felt supported to raise concerns and felt staff treated them with compassion and understanding. Staff were encouraged to raise concerns when things went wrong. Lessons learnt from complaints and significant events were discussed during staff meetings and recorded in the minutes to ensure improved care for all patients. Follow up on clinical searches during the assessment process was completed promptly.

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 service maintained a safeguarding register and acted on concerns working in partnership with other organisations. However, records of patients on the safeguarding register we reviewed, showed that not all household members of such patients were coded. Following the site visit, the service informed us that the practice had started to complete the process to rectify the concerns found during the site visit.

The service did not work well with people to understand and manage risks. They did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Emergency equipment was not complete and appropriately maintained. There was no evidence of regular audits to ensure that emergency equipment met the required standards. For example, the anaphylaxis kit contained two 23G needles instead of the four recommended by the Resuscitation Council UK, many of the items used in the resuscitation of a patient in cardiac arrest were missing or out of date. Following the site visit, the practice informed us that they would implement steps to ensure that the emergency equipment was up-to-date. However, staff could recognise a deteriorating patient and demonstrated an understanding of the actions required in response. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. The premises were not owned by the practice. The cleaning contracts in place to ensure the premises were maintained were held by the building owner. Health and safety risk assessments and audits were not seen during the CQC visit. The practice informed us that these records were held by the landlord and had not been provided as requested by the practice when CQC announced the site visit. The practice was unable to show if any risks identified in the assessment had been addressed. The fire risk assessment was current and fire drills, and alarm testing were recorded. There was a business continuity plan in place which was monitored and reviewed. Calibration of clinical equipment was routinely completed and the certificates seen during the site visit.

The service made sure there were enough qualified, skilled and experienced staff. They worked together well to provide safe care that met people’s individual needs. Safe recruitment practices were followed and staff worked within their agreed areas of competence. They made sure staff received effective support, supervision and development. However, our review of staff training records showed that not all staff had completed their required training. Following the site visit, the practice informed us that staff training gaps would be addressed.

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. The practice had a designated infection, prevention and control (IPC) lead and all staff had received relevant training. Cleaning schedules were in place and were reported to be followed, with oversight from the landlord. However, evidence of this oversight was not provided at the time of the assessment. Risk assessments such as Legionella were not completed. The Legionella risk assessment report of April/ June 2024 provided after the site visit identified 8 defects that were classed as urgent priority, 11 defects classed as high priority and 9 defects classed as moderate priority all related to water safety at the practice. However, there was no evidence that the practice took or ensured any appropriate actions were completed.IPC audits that had been completed did not identify all risks associated with the delivery of primary care services. For example, there was no assurance that all staff vaccination records had been obtained and reviewed, and there was limited evidence of action taken to mitigate risks identified through the IPC audits. Following the site visit, the practice informed us that the IPC processes will be enhanced.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened. 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. Staff received regular training, were competency assessed on medicines optimisation, and felt confident managing the storage, administration and recording of medicines. Staff managed prescription stationery appropriately and securely. However, there was no log of the serial numbers of the prescription forms. Patient group directions (PGDs) were current and authorised by appropriate clinicians. Patient specific directions (PSDs) used by the health care assistants at the practice were not documented in the patient records and the file kept by the practice for PSDs was not found during the site visit. However, PSDs authorised by the lead clinician during the site visit were seen.

Staff followed protocols to ensure they prescribed all medicines safely, and ensured people received all recommended medicines reviews and monitoring. Medicines were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines. A data logger was used to back up manual readings of vaccine fridges and staff understood the protocol to follow if temperatures were out of recommended range. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments. However, there were no risk assessments completed for emergency medicines that were not carried by the service such as naloxone and atropine. The practice did not have antiemetics (medicine to stop nausea and vomiting), benzylpenicillin (for treating bacterial meningitis), and diclofenac injection (for the treatment of pain in an emergency). Emergency medicines for the treatment of severe pain such as morphine, pethidine and diamorphine were not stocked by the practice.Following the site visit, the practice informed us that action had been taken to ensure all required emergency medicines are in place and where needed comprehensive risk assessment developed to review the necessity of each medicine.

The provider was responsive in addressing the concerns found during the clinical searches. For example, 6 patients on citalopram/ escitalopram that did not have dosage reduced as per historic Medicines and Healthcare products Regulatory Agency (MHRA) safety alert or informed of the risks associated with prolonged use, were followed up by the clinical pharmacist and action completed by the end of the site visit day. Patients with a potential missed diagnosis of diabetes as identified during the clinical searches had been followed up by the end of the site visit day. Patients that were on medications that could increase their risk of gastrointestinal bleeding identified from the clinical searches were followed up by the end of the site visit day. The practice completed audits for the affected patient groups.

Staff followed established processes to ensure people prescribed medicines with specific risks received the recommended monitoring. They also followed up with patients who did not engage with the service to ensure required blood tests were completed. However, the context of medication reviews was not always recorded. Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. Prescribing data reviewed as part of our assessment confirmed this. For example, the number of antimicrobials issued by the provider was in line with the local and national averages. In addition, the number of prescribed psychotropics and hypnotics was lower than the local and national averages. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.