Sheepcot Medical Centre

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. The service was in breach of legal Regulation 17(1) and 17(2), Good Governance, of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This key question has been rated as Inadequate.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider processes for staff to report incidents, near misses and safety events required strengthening to embed good practice into the workplace. For example, there was a policy in place for systems to record and investigate complaints, and when things went wrong, however, this was not logged formally and there was not enough policy detail. Managers encouraged staff to raise concerns when things went wrong. During staff meetings, the whole team discussed and learned from clinical issues. Staff felt there was an open culture. The provider told us they would review this and showed they were demonstrating a willingness to embed better policies. Systems and processes for managing complaints were ineffective. We reviewed 2 samples of complaint responses and identified that both complaint responses did not have details of the Parliamentary and Health Service Ombudsman. We requested a copy of the complaints log for the previous 12 months and we were told there was no formal tracker. Complaints were not always documented with actions and it was unclear what actions had been taken. The practice implemented a tracker following our inspection. There was a duty of candour policy within date. Significant events were not formally logged. The provider had acknowledged the need for a more formal approach monitor how many significant events had been reviewed. The provider shared 1 significant event with us and told us there was no formal tracker for these and they were held in a folder with administration staff. Following our assessment, the practice told us they would be implementing a tracker for significant events and complaints. We reviewed the processes for Medicines and Healthcare Products Regulatory Agency (MHRA) safety alerts. There were 125 out of 139 people prescribed a diabetes medicine (sodium-glucose co-transporter 2 (SGLT2) inhibitor) who had not received the appropriate guidance for diabetic ketoacidosis or Fournier’s gangrene.

The service did not always establish and maintain safe systems of care and did not always manage or monitor people safely. They did not always make sure there was continuity of care, including when people moved between different services. We completed a suite of remote clinical searches and found that 15 out of 48 people prescribed Methotrexate had not received the appropriate monitoring as per national guidelines. We randomly sampled 5 patient records and found that 4 of these patients had not received the appropriate monitoring. Without the appropriate monitoring, people were at risk of not having the correct dose of Methotrexate. There were shared care agreements when people were monitored by secondary care. The risk to people was if they became unwell with these side effects, they would not know what action to take. We told the provider to review these people, and they actioned this request immediately; however, we will continue to keep this under review to ensure embedded processes are operating effectively. Furthermore, we reviewed the staff training matrix and saw that 4 out of 31 staff had completed sepsis training and 17 out of 31 staff had completed sepsis awareness training. The practice told us they would discuss sepsis training with their training provider to ensure the correct sepsis training was completed by staff. We saw sepsis awareness posters placed around the building and in the reception areas; however, the staff we spoke with could not explain the signs of sepsis and were unaware of the posters within the building.

The service did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect. They did not always share concerns quickly and appropriately. We reviewed staff safeguarding training and identified that 17 out of 31 staff had not completed safeguarding adults training level 2. We saw that only 1 staff member had completed level 3 safeguarding adults training. Additionally, 19 out of 31 staff had not completed safeguarding children training level 2 and only 6 out of 31 staff members had completed level 3 safeguarding children training. Following our assessment, the provider sent some certificates of completion of training for staff who had not completed. The provider did not have a female genital mutilation policy. Safeguarding meetings were held monthly with a multidisciplinary team. Not all staff could not tell the inspection team when we visited on site where the safeguarding posters and flow charts were, despite them being visible in the reception area. Staff had disclosure and barring service (DBS) checks appropriate for their role. The provider did not have an up to date policy for DBS checks and submitted an updated version following our on-site inspection.

The service did not work well with people to understand and manage risks. Following our assessment, the provider showed us completed staff training. During our on-site visit on 16 December 2024, we reviewed emergency medicines. The emergency medicines were stored inside a locked room with a key code entry and then behind a locked cupboard which required a key from another cupboard to open this. The provider told us this room was assessed as the most appropriate and central room to the ground floor of the building, to access emergency medicines when required. There was a separate cupboard upstairs which was again locked behind a locked door. The national resuscitation guidelines state emergency medicines should not be locked or kept in locked rooms or cupboards. Therefore, there was a risk that patients would not receive timely treatment in the event of an emergency due to inadequate systems and processes in place. They did not provide care to meet people’s needs that was safe, and supportive and enabled people to do the things that mattered to them. When we reviewed how emergency medicines were stored, we saw they were not kept on the emergency trolley. The only medicine kept there was an anaphylaxis box. We also found these emergency medicines were not stored in individual boxes; for example, we observed there were vials of Adrenaline and water for injection in unboxed vials, held together by an elastic band in a plastic lidded container. There was a risk of harm to the service user if the emergency medicines were inaccessible. Additional risk was identified from mixed unboxed medicines meaning that patients were at risk of having an incorrect medicine administered in an emergency.

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. Contracts were in place to ensure the premises were maintained. A fire risk assessment was completed in November 2023 and the provider premises were rated as moderate risk. There were incomplete updated required actions, and we could not be assured the provider was compliant with their fire risk assessment. There was a business continuity plan in place which was monitored and reviewed. The staff training matrix detailing practices deemed mandatory training for health and safety was not up to date. We saw 19 out of 31 staff had not completed training for health and safety. The provider did have evidence of electrical and portable appliance testing certificates. There was also evidence of calibration of equipment completed. The practice did not have a disability risk assessment in place. However, we did observe during our on site inspection that the building had been purpose built and all doorways were wheelchair accessible, there was a lift available and toilets were disability friendly with pull cords and grab rails. There were 2 fire wardens at the practice. A health and safety audit had been completed.

The service did not always make sure there were enough qualified, skilled, and experienced staff. They did not always make sure staff received effective support, supervision, and development. They did not always work together well to provide safe care that met people’s individual needs. There were a range of clinical and non-clinical roles within the practice. We found the training was not up to date, the learning needs and development of staff was not always managed appropriately. For example, staff did not have formal supervision for their clinical competence. Additionally, there was no formal process in place for staff appraisals. This meant staff were not being effectively monitored and supported. Safe recruitment practices were not always followed. A spot check of recruitment files showed missing documents, for example, a GP file was missing photo identification and for the 3 administration staff files reviewed, we observed only 1 reference which is not in line with schedule 3 recruitment guidance. There was no risk assessment for the emergency medicines as recommended by the national resuscitation guidelines. There was a risk that not all recommended emergency medicines were available to ensure effective treatment to service users in an emergency. The Atropine medicine was kept in a different clinical room and there was no associated risk assessment to accompany the storage of this medicine. Additionally, on the site visit completed on 16 December 2024, when asked where this emergency medicine was kept, not all staff were aware and had to go look around the building for this. There was a risk of harm to the service user if the emergency medicine was inaccessible. We identified that 19 out of 31 staff had not completed anaphylaxis training.

Systems and processes for infection control were not robust. The training matrix we reviewed, identified that 20 out of 31 staff had not completed infection prevention, and control training level 1 and that only 2 staff had completed infection, prevention, and control training level 2. This was not in line with NHS England National Infection Prevention and Control Guidelines (2022). Furthermore, we found that there were not robust processes in place for the oversight of infection prevention and control management. There was 1 audit available that was dated 2020 and no other audits were available. There was no evidence to demonstrate monthly infection prevention and control ( IPC) checks had been completed. There was no clear policy for infection prevention and control. The practice provided a 1 page bullet point infection control overview which did not include any requirements that should be detailed within an infection prevention and control policy. The practice were using an infection prevention and control handbook referencing guidelines dated 2017. This did not have the most current and up-to-date guidance held within it. We observed a blank infection prevention and control toolkit that was not completed. Not all staff had competency assessments for handwashing or personal protective equipment which the provider told us during our on-site visit were deemed mandatory. Infection prevention and control posters were not all in date and a spot check of the cleaning cupboard showed that mops were stood in buckets with mop heads still attached. When we reviewed the systems they had in place for cold chain monitoring, there was a lack of oversight to ensure the designated staff were following the NHS England policy and procedure for maintaining the vaccine cold chain (2022) guidelines to ensure cold chain compliance. Although we were provided with daily temperature log sheets completed twice a day, dated with twice daily checks, there was no time of day documented,

The service did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. We found 102 people who had a potential missed diagnosis of chronic kidney disease (CKD) stages 3-5. The risk to these people was that they could be unwell from not being on a CKD monitoring register and deteriorate. A random sample of 5 of these records showed that 4 people had a missed diagnosis of CKD 3, while 1 person had not received blood monitoring. There had been 1419 medicine reviews completed and a random sample of 5 records identified there was no content to the medicine review. We told the provider to implement a protocol for documenting a medicine review and they provided this information to us following our inspection. People aged over 65 and identified 86 out of 247 people were prescribed a non-steroid anti-inflammatory medicine and/or antiplatelet medicine with no gastric protection medicine. This is a risk to people as they would be pre-disposed to stomach bleeding without any gastric protection. The management and oversight of blank FP10 prescription forms was not effective or in line with the NHS Counter Fraud Authority management and control of prescription forms (March 2018) guidance. During our site visit on 16 December, we found there was no effective oversight of the voiding of prescriptions to minimise the likelihood of theft or misuse. We did not see evidence that blank prescriptions were being stored, managed, or destroyed appropriately. We did not see evidence of appropriate policies in place for the use of blank prescriptions by locum GPs, or when blank prescriptions were taken on home visits. This increased the risk of prescription forms being stolen and/or misused to obtain medicines inappropriately.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.