Askern Medical Practice

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• 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 was in breach of legal regulations in relation to safeguarding service users from abuse and improper treatment, fit and proper persons employed and receiving and acting on complaints.

This service scored 44 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

At the previous inspection we scored this quality statement as a 2. This was because we were not assured that complaints had been dealt with effectively and lessons learned from them. We did not feel that significant event documentation was in depth enough or that there was a monitoring log of these which was held centrally to be re-assured they were being picked up and managed fully.

At this assessment, concerns identified at the previous inspection remained evident, with little or no demonstrable improvement. This indicated insufficient recognition of the need for improvement and a lack of timely and effective action to address previously identified issues.

The provider was unable to demonstrate consistent learning from complaints as reported under the key question responsive under the quality statement ‘Listening to and involving people’.

The provider was unable to demonstrate a clear or effective system for managing significant events. We received 2 different versions of a significant/learning event log. The records did not show the same significant events. We were also made aware by a member of staff of a significant event where a vaccine had been administered by a staff member not qualified to do so. A record reporting this event was available, but this record did not form part of the overall recording log. The provider could not demonstrate what action had been taken in respect of the member of staff administering the vaccine as there was no record of this in their personnel file.

We were told by a member of staff that the current system for managing significant events was not fully effective.

Staff that responded to our questionnaire described that learning from incidents and feedback was embedded into routine practice through systems and processes including multi-disciplinary teams (MDT) meetings, audits, and small group meetings. Examples of changes implemented as a result of significant/learning events was provided.

Representatives from the Patient Participation Group (PPG) told us the provider took concerns seriously and proactively made improvements to the service.

Safety processes were not aligned with other key partners who were involved in people’s care journey. We found that although the service worked with other providers to deliver shared care, we also found that they did not always work well with people and healthcare partners to establish and maintain safe systems of care.

Multiple inboxes on the services computer system identified during the assessment contained ‘not-started’ clinical tasks and requests, including those from external healthcare partners. The service was not clear at the time of our assessment what these inboxes were used for. As part of reviewing the ‘not started’ tasks we reviewed some patient records in detail as was concerned by our initial findings.

The review of records showed that multiple discharge notifications from out-of-hours services (some received in quick succession) were filed by clerical staff with limited evidence of further action. This included child safeguarding information which was not consistently reviewed by clinical staff, appropriately escalated, or considered in the context of the wider safeguarding picture.

Records showed that requests for information and advice from other services (including notifications and correspondence that contained safeguarding concerns, clinical queries, and requests for onward assessment or treatment) were not always reviewed or responded to. This included requests from services involved in a child’s care that raised concerns about a child’s welfare and the health needs of a parent, requests for x-rays and retinal screening.

Some staff reported a lack of cover during periods of absence, resulting in a backlog of non-urgent tasks.

Systems were in place to manage referrals and test results. For example, two week wait referrals and pathology results.

At this assessment we found significant concerns with the way safeguarding was managed by the service.

We found that effective systems and processes were not in place to ensure patients were safeguarded from abuse. Our review of patient records identified significant concerns. Safeguarding children registers kept by the service were not always up to date. Concerns and information were not consistently recorded in patient records. This was not in line with the provider’s own policy and the General Medical Council professional standards. The provider could not therefore demonstrate that patients on safeguarding registers were regularly reviewed and information updated to avoid harm.

Safeguarding concerns were not always visible to staff accessing the patient records which limited awareness by staff of the risk(s) present and increased the likelihood that safeguarding needs were not identified or acted upon in a timely way. For example, the provider did not ensure relevant safeguarding codes, alerts or high-priority reminders were recorded on the patient record or on the record of other relevant linked individuals such as family or household contacts, meaning associated risks were not clearly visible to staff. The provider was unable to demonstrate evidence of a structured transition review before children were removed from the child safeguarding register when they reached 18. Ongoing risk was not routinely considered during this period of potential increased vulnerability. We found an example where this had not happened and a patient had not been considered for inclusion in the adult safeguarding register.

The provider was unable to demonstrate that all staff had completed safeguarding training relevant to their role and at the appropriate level which meant staff may not be able to identify and act on potential safeguarding concerns, thereby placing service users at potential risk of harm and abuse. For example, not all clinical staff had completed Safeguarding Level 3 and Learning Disability and Autism training. The provider was not following the training requirements set out in their own safeguarding children’s policy. Training information for sessional GPs, a locum GP, a locum nurse, and several staff within the Additional Roles Reimbursement Scheme (ARRS) was not kept and therefore the provider was unable to evidence what training they had completed.

The provider did not always investigate immediately upon becoming aware of an allegation or evidence of abuse. For example, we found examples where queries from external agencies relating to patients who were at risk had not been responded to. Tasks classed as ‘not started’ were evident in the records of patients known to be at risk.

The provider’s safeguarding children policy did not set out the arrangements for when a child was not brought to an appointment. As such, missed appointments for children were not appropriately recognised as potential safeguarding concerns. This limited staff awareness of risk and reduced appropriate safeguarding follow-up. Missed appointments, particularly where safeguarding concerns are known, may indicate unmet need or increased risk of harm, and they require timely, coordinated action. Patient records showed this. A ‘DNA (did not attend) and discharge quick guide’ was submitted by the provider during the CQC factual accuracy process. We found the quick guide was not always followed by staff.

We identified concerns about the risks to patients from the way safeguarding and safe systems, pathways and transitions were managed.

From our clinical searches we found the service worked with people to understand and manage risks by thinking holistically and that they mostly 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 what action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

We found 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 audits had been undertaken and risks identified had been addressed. There was a business continuity plan in place which was monitored and reviewed.

CCTV was in use at the service. At the previous inspection, concern was raised by staff regarding its use. No concerns were raised at this assessment. The service was registered with the Information Commissioner’s Office (ICO) for the use of CCTV, and evidence of this registration was available.

At the previous inspection we scored this quality statement as a 2. This was because there was no overall oversight of Disclosure and Barring Service checks, no system to flag to the provider if and when a new check was needed and no oversight of staff vaccinations.

At this assessment, concerns identified at the previous inspection remained evident, with little or no demonstrable improvement. This indicated insufficient recognition of the need for improvement and a lack of timely and effective action to address previously identified issues.

The service did not ensure robust and safe recruitment practices to ensure that staff employed were of good character and had the qualifications, skills, and experience necessary to carry out their roles safely and appropriately. The service could not evidence that their recruitment policy and their clinical supervision policy were being adhered to.

We reviewed and discussed the personnel records for 5 members of staff and found that key information was not consistently recorded or accessible. We looked in detail at the records for 4 members of staff. A basic summary of the findings is detailed below:

• Enhanced Disclosure with Barred List (EDBL) checks (with checks made against both Barred Lists) from the Disclosure and Barring Service (DBS) were not completed for those staff who would be expected to have such a check due to the nature of their role. In all 4 paper personnel records we looked at, appropriate EDBL checks had not been completed. For example, 1 member of staff had a ‘basic’ DBS check which was not an appropriate check and this had been completed after they had commenced employment. There was no risk assessment on file to support the decision not to carry out the appropriate EDBL DBS check for any of the staff members we reviewed. Although additional information was supplied during the CQC factual accuracy process, this did not address the wider concerns identified, as gaps in EDBL information remained across the records reviewed.
• Gaps in other pre-employment checks such references, employment history, vaccination status and oversight of right to work were found. Although some additional pre-employment information was supplied during the CQC factual accuracy process, this did not address the wider concerns identified, as gaps in pre-employment information remained across the records reviewed.
• Gaps in relation to the provider following their own clinical supervision policy were found.

We found that training records were not consistently maintained for all staff. The provider could not demonstrate that all staff had completed the mandatory training required by the service.

Most staff reported enough time to complete training. Some staff provided positive feedback regarding opportunities and support for personal development in their employment.

There was limited evidence to demonstrate that effective systems were in place to support the consistent implementation of the practice’s clinical supervision policy.

The policy lacked sufficient clarity on how staff performance and competencies were to be monitored, and it had limited application across the clinical workforce.

The systems for recording, reviewing, or evidencing staff support, training, professional development, supervision, and appraisal were not consistently implemented, which reduced assurance that staff had appropriate skills and competence which are necessary for the work to be performed by them.

At this assessment we found 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.

Cleaning schedules were in place and followed. Both sites were observed to be visibly clean.

Risk assessments and audits were completed, and actions taken to mitigate risks.

The service had a designated infection, prevention and control lead. IPC training was mandatory for all staff and information provided by the provider showed that all staff had completed either Level 1 or 2 training. However, the staff training record shown to us was incomplete and therefore the provider was not assured that all staff working at the services sites had undertaken all relevant training to undertake their role.

We also found the service did not maintain records of staff immunisation status in line with national guidelines. This issue was identified at the previous inspection.

We found that the service ensured that medicines and treatments were safe and met people’s needs, capacities and preferences and involved people in planning when changes happened, however, some concerns were identified. Specifically, these related to the management of patient group directions (PGDs), medication reviews and the management of prescription stationery.

Patient group directions (PGDs) are a legal framework that allows some registered health professionals to supply and/or administer specified medicines to a pre-defined group of patients without them having to see a prescriber (such as a doctor or nurse prescriber). During the review of these documents, we were supplied with paper copies of the PGDs. Almost all were incorrectly authorised. We were supplied with different PGDs after the assessment. Whilst this showed improved governance, some of the PGDs supplied were signed after they became active; some had been authorised before the nurse had signed them and there was no striking through of blank lines on the PGD as required in best practice.

Prescription stationery was recorded into the practice. However, reception staff did not remove stationery from the reception printer at the close of the day which was not in line with the process described by the practice manager.

As part of our assessment, we interviewed the clinical lead GP and practice pharmacist. They explained the systems in place for the appropriate and safe use of medicines, including medicines optimisation.

A series of patient clinical record searches were undertaken by a CQC GP specialist advisor. This included a review of patients prescribed medicines requiring monitoring, as well as an evaluation of prescribing practices and the quality and effectiveness of medication reviews. We saw evidence of reasonable and proactive actions taken to encourage patients to attend the practice for timely reviews and to ensure safe prescribing decisions. During the assessment, feedback was provided to the provider confirming that no concerns regarding patient harm were identified. However, a small number of issues arising from the clinical searches were highlighted for the provider to review and assurance was provided.

We reviewed prescriptions awaiting authorisation and found these were up to date.

People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms.

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 managed the storage, administration and recording of medicines.

Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines. 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. The medicines optimisation (prescribing) data which is received by CQC from the NHS business services authority (NHSBSA) showed that in 5 out of the 6 indicators available to us there was no statistical variation between the service and the national average. One indicator, the prescribing of certain medicines for uncomplicated urinary tract infections was identified as ‘negative variation’ meaning prescribing data for the practice was slightly higher than expected. The service was 6.53 compared to 5.03 expected. We discussed this with the lead GP and the clinical pharmacist. The lead GP described how they have amended their prescribing and recording of rationale for prescribing.

There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.

Staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely. A high volume of patients received medication reviews. The reviews we looked at identified no concerns. However, we saw that patients were routinely booked in for annual medication reviews up to 9 months early and this impacted negatively on appointment availability. Patients scheduled months early for annual medication reviews were often then rescheduled to accommodate urgent cases, which may cause them inconvenience. We received patient feedback regarding appointments being changed (the feedback did not specify the type of appointment) and saw complaints regarding multiple appointment changes. One specifically referred to medication reviews which had been directed to the Primary Care Network Pharmacy team. The provider explained they had a transient patient population, which made it challenging to ensure all patients attended review appointments such as medication reviews.