Mallard 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

There was a risk that patients were not protected from abuse and avoidable harm because the service did not always have a proactive and positive culture of safety based on openness and honesty. At our last assessment, we rated this key question as Good. At this assessment, the rating has changed and is now rated as Requires Improvement. The service was in breach of legal regulations in relation to staffing, recruitment and the governance and assurance of safety information and events. We have asked the provider for an action plan in response to the concerns found.

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 listened to concerns about safety and investigated and reported safety events. However, the arrangements for ensuring these were communicated and embedded into good practice were not effective. Practice staff meetings did not happen routinely, and staff reported they did not get feedback about learning from significant events, patient feedback and complaints. Staff told us when they had raised concerns they felt ignored and devalued. They told us there was a blame culture and that divisions in the GP partnership had caused difficulty in identifying, agreeing, and implementing improvements. There was no Patient Participation Group and there was a lack of mechanisms in place to listen and learn from patient feedback to improve safety. Although leaders told us they encouraged staff to raise concerns when things went wrong, we identified the culture in the practice was acting as a barrier and staff did not feel supported to raise concerns. This meant safety was not always prioritised. Although there were processes for staff to report incidents, near misses and safety events the culture and communication mechanisms within the practice meant this was not always effective. Learning from incidents and complaints resulted in some changes that improved care for others.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

The recruitment practices in place did not provide sufficient assurances that staff were suitably experienced, competent, and able to carry out their role. The practice had not routinely maintained records required for safe recruitment, such as Disclosure and Barring Service (DBS) checks; checks on relevant qualifications; checks of registration with relevant professional regulators; and checks on proof of identity. Although leaders had identified some of these issues during preparation for the assessment and started to address them, assurance processes were not yet fully in place. There were no written risk assessments in place where staff did not require a DBS check, to document the reasons and risk management in place. There was no audit trail maintained for decisions about DBS checks. We found training was mostly up to date but there were some gaps. Most non-clinical staff had not received level 2 training in the safeguarding of children and adults. This was recommended for all staff who work in health care who have regular contact with patients. There was no evidence to demonstrate staff had received training in Health and Safety in line with regulatory requirements. Some staff reported good levels of support and supervision from GP Partners. However, we found these were not always recorded and there was inconsistency in the frequency of these. Whilst we did not identify risks to patients due to staffing levels, we did find arrangements were at risk due to lack of sustainable staff planning. There was high staff turnover and high levels of staff dissatisfaction. Leaders had not identified the reason for these and did not have an effective strategy in place to address this. Short term cover for absences was based on staff good will, but there was a high risk this would not be sustainable due to ongoing low staff motivation. The GP Partners told us they were in the process of recruiting a new practice manager and additional administrative / reception resources.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

The service made sure that medicines and treatments were safe and met people’s needs, capacities, and preferences. 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 followed protocols to ensure they prescribed all medicines safely, and ensured people received all recommended medicines reviews and monitoring. Medicines including controlled drugs were stored securely and at appropriate temperatures. Staff checked the stock levels and expiry dates for all medicines, including emergency medicines, vaccines, and controlled drugs. Waste medicines were recorded and disposed of appropriately including medicines returned by patients. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments. The provider had effective systems to manage and respond to safety alerts and medicine recalls. Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring. Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. Prescribing data we reviewed as part of our assessment confirmed this. For example, the number of antimicrobials issued by the provider was in line with comparators. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment. However, there were some emergency medicines recommended by the Resuscitation Council UK that were not stored on site. There was no risk assessment in place to demonstrate why these were not needed or to document alternative arrangements to manage the risks.