Teldoc-Lawley 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 found that the care and treatment of people needed strengthening to ensure systems in place were effective in providing appropriate care. Improvements were required in the management of medicines, the security of prescriptions and emergency medicines. The provider had effective systems for the management of risk, this included the safety of the premises. Processes for the actioning of incidents and significant events with learning shared across the teams. All staff understood the importance of keeping people safe and we found safeguarding registers were in place and well maintained. When there were concerns identified about people’s safety these were actioned.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff and leaders understood their duty to raise concerns and report incidents and near misses. We saw evidence that any actions or lessons learned was discussed in practice meetings. Staff and leaders were able to share examples of incidents and complaints which had been investigated and staff told us they felt they were able to raise concerns and report when things went wrong. Feedback from staff and leaders demonstrated that the practice had a culture of identifying incidents and complaints, learning and improvement to continually identify and embed good practices.

The practice had a significant events policy and a reporting form which was accessible to all staff members. The practice had a significant events lead responsible for supporting staff in identifying and reporting significant events. All significant events and incidents were recorded centrally and discussed at regular significant events meetings. The practice had a duty of candour policy and involved people when managing significant events and errors. The practice had a clear system in place to record and investigate complaints. From the sample of complaint records we reviewed; we found the practice responded to people’s complaints in a timely manner. The practice offered apologies to people, lessons were learnt from individual concerns and complaints and action was taken as a result to improve the quality of care.

 

Leaders told us that clinicians made appropriate and timely referrals in line with protocols and up to date evidence-based guidance. This was supported by a system in place to ensure all patient information including documents and referrals were reviewed and actioned in a timely manner. On reviewing the clinical system, we found 3800 outstanding tasks dating from September 2022. An investigation was commenced by the leadership team to ascertain what had occurred. Following the onsite assessment, we received assurances that the outstanding tasks had been reviewed and there was no evidence that urgent tasks had been missed. The investigation had found that some of the tasks were in the inboxes of staff that had left the practice and had not been allocated to another member of the team. The inboxes were cleared and the staff members removed to mitigate future risk.
There was a system for processing information relating to new patients including the summarising of new patient notes. There were systems in place for referrals to appropriate services, which was managed in a timely way.
 

There were policies and processes in place to keep people safe and safeguarded from abuse. The practice had a safeguarding lead for adults and children and all staff had completed safeguarding training to the required level for their role. The practice held a safeguarding register, and patient records we reviewed showed that they had been appropriately coded where safeguarding concerns had been identified. Clinical system alerts were used to identify patients who were at risk of harm or abuse. There were processes in place to follow up children and young people who were not brought to their appointments both at the practice and for secondary care appointments. Safeguarding meetings were held on a regular basis to review patients at risk.
There was a policy in place for the renewal of DBS checks. Records we examined showed that all staff had a DBS check in place. DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable.
 

On reviewing the clinical system, we found that processes required strengthening to manage risks. For example, there were registers to manage patients prescribed high risk medicines, however we found some patients potentially had not been monitored appropriately. Following the onsite assessment, we were provided with evidence to demonstrate that the remote clinical searches had been reviewed and some coding issues may have impacted on the search results. All patients identified had been reviewed by the clinical leadership team. Leaders told us that they worked with services locally to understand and manage risks. For example, there were regular primary care meetings held with other agencies to work holistically so that care met patients’ needs and services managed care holistically.
The practice had registers in place to support those patients who were vulnerable or who had mobility or communication needs. Evidence provided showed there were 230 people on the learning disability register. Since 1 April 2024 146 patients had received an annual review and a further 22 people were booked in for a review. This demonstrated 72% of people on the learning disability register had been assessed to ensure their needs was being met.
All staff were trained in basic life support and receptionists were aware of actions to take if they encountered a deteriorating or acutely unwell patient and had been given guidance on identifying such patients. There were processes in place to ensure the practice prioritised care for their most clinically vulnerable patients and patients were told when they needed to seek further help and what to do if their condition deteriorated.
 

There were policies and procedures in place for the management of health and safety. Fire safety policies were in place and staff were aware of how to access these. Fire marshals had undertaken additional training for the role. Systems were in place for the regular checks of fire alarms, extinguishers and fire evacuation procedures and a fire risk assessment had been completed.
The practice had completed assessments in place for the control of hazardous substances. We were unable to gain assurances that the calibration of equipment was regularly completed. For example: weighing scales had not been calibrated since 2022.
During our site visit we found the premises were visibly clean. There were a variety of processes in place to ensure the environment was safe. A health and safety risk assessment had been completed and a range of actions had been identified. A fire risk assessment had also been completed and regular checks of firefighting equipment was in place.
Vaccine fridge temperatures were recorded in line with the practice policy on a daily basis and data loggers were downloaded weekly.
 

There were policies and procedures in place for the safe recruitment of staff and the organisation had implemented an outside company to review the current human resources processes and implement new systems for the recruitment and training of staff. The leadership team told us they had completed disclosure and barring checks (DBS) for all staff working in the practice and that all newly employed staff had completed an induction to ensure they were competent in carrying out their role.
There were clearly defined lead roles to support staff in carrying out their roles effectively and staff were supported by leaders. The practice had a programme of learning, which was monitored by the leadership team. We found that staff were up to date with training requirements, which included newly appointed staff. There were staffing rotas to ensure there were adequate cover in place.
A recruitment policy was in place which included how the practice processed personal data in accordance with the General Data Protection Regulations (GDPR) and the policy outlined the requirements to obtaining a full employment history for prospective staff prior to employment.
We reviewed 10 personnel files and found appropriate checks such as previous employment record, proof of identity and clinical staff files had evidence to demonstrate that clinical registration checks had been completed. Personnel folders were well organised and there was a systematic approach to ensure that personnel folders were managed appropriately. We found staff immunisation status records were not in place for all staff and no risk assessments had been completed in their absence to ensure risks to staff and patients had been considered. Following the onsite assessment we received a risk assessment that had been implemented for staff who worked in non clinical roles and were at reduced risk of infectious diseases. We were told that clinical staff were required to complete an immunisation status form as part of pre-employment checks in accordance with the organisations staff screening and immunisation policy. However, we were unable to confirm on the day of the onsite assessment immunisation status for a number of clinical staff.
We found that processes were in place for supervision and oversight and staff had access to regular appraisals, clinical supervision and were supported to meet the requirements of professional revalidation. The leadership team were able to demonstrate how they assured the competence of staff employed in advanced clinical practice. We were told there were a range of clinical staff available to provide care to people. These includes physician associates, nurse practitioners, practice nurses, health care assistants, physiotherapists, paramedics and clinical pharmacists. Teldoc is a training practice for GP registrars.
 

The practice had policies in place for infection, prevention and control which was accessible to staff. On reviewing the policy we found the policy had been updated in 2024, but did not reflect the needs of the practice. For example: the policy made references to other policies that did not exist such as re-use of surgical instruments. On speaking with staff we found staff were aware of where the spill kits were allocated in case any spillage accidents occurred in the practice. Sharps bins were available in all clinical rooms but we found that some of them had not been dated when opened. The sharp bins were safely sited and were not over-filled.An infection control audit had been completed in October 2024. The practice had achieved 100%.

We found emergency medicines were not being managed or stored appropriately. On reviewing the emergency medicines, we found they were kept in an unlocked cupboard which was accessible to the public.
Prescription paper was not being stored securely. 95% if the prescriptions issued were by electronic prescriptions direct to the pharmacies, however on reviewing the log sheets for prescriptions we found the serial numbers of the prescriptions had not been recorded appropriately. Following the onsite assessment, we received assurances from the provider that they had reviewed the discrepancies and as they were in the process of transcribing the paper logs to digital format, it appeared that some of the logs were incomplete at the time of the inspection. We received assurances that the digital formatting had now been completed and the ongoing plan was a new system to be implemented to ensure the digital prescription logs were audited on a monthly basis. The organisation had also updated their policy to reflect the changes.
We found that the practice had not taken action to review some safety alerts to ensure that these were being followed appropriately and to ensure people were protected from harm. For example: we carried out a clinical search for people who had prescribed medicines to reduce blood sugars by helping the kidneys to remove the excess sugar or glucose through urine. The medicines had the potential to cause a rare but life-threatening infection, and all people prescribed these medicines were to be advised of the side effects and risks. The clinical searches potentially identified 99% of people on these medicines had not received any advice. Following the onsite assessment, we received evidence to demonstrate that the advice had been given to people but had not been clinically coded correctly so had not been found during the clinical searches. We received assurances that the correct coding will be used going forward following the on site assessment.
Clinical searches of patient records were carried out as part of our inspection. A medicine (methotrexate) to treat rheumatoid arthritis which requires regular blood monitoring due to the risk of side effects, was looked at. It was found there were 144 patients who were prescribed this medicine. We reviewed a random sample of 5 clinical records and found the latest guidance had not been followed as all people taking this medicine need to have the day of the week when the medicine is taken to be added to the prescription. Following the onsite assessment, we received assurances that this is in the process of being actioned.
A search was done for monitoring patients on a high-risk medicine, which is used to prevent strokes in patients. The medicines belong to a group abbreviated to DOACs. We found 604 people on DOACs which potentially showed 70% of the patients had an out-of-date creatinine clearance. A creatine clearance informs clinical judgment on whether a person is taking the right dose of medicine. This is a concern as people are at risk of bleeding if the dose is too high or a risk of blood clots if the dose is too low. Following the onsite assessment, we received evidence to demonstrate that there had been a coding issue as the clinical team use a different process for the calculation. A total of 91% of patients had creatinine clearance calculated and the remaining people required a review.