Sefton Ave Surgery Also known as Mulberry 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

We looked for evidence that people were protected from abuse and avoidable harm. Recruitment records did not provide assurance that appropriate checks to support the safe recruitment of staff had taken place. We were not assured, based on the evidence provided, that staff received regular supervision and appropriate monitoring to ensure high-quality care. Training records showed gaps in mandatory training around safeguarding and mental capacity.

We did not find evidence that fire risk assessments had been completed across the three sites at the time of inspection, representing a lapse in compliance and a potential fire safety risk. Although fire risk assessments and an action plan were submitted following our on-site visit, concerns remained regarding oversight by the practice. Infection prevention and control risks were identified by the practice, but risks were not managed as an interim measure to mitigate risks pending resolution with landlords. While some aspects of medicines management were effective, some areas required strengthening.

At our last assessment in 2016, we rated this key question as Good. At this assessment, the rating has changed to requires improvement.

The practice was in breach of legal regulation in relation to safe care and treatment.

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.

Staff felt supported to raise concerns and felt leaders treated them with compassion and understanding. Leaders encouraged staff to raise concerns when things went wrong. Staff felt there was an open culture.

The practice could not demonstrate a culture that consistently supported effective learning and development. The practice did not have full oversight to ensure all staff were up to date with mandatory training requirements.

The practice had processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints and when things went wrong, staff apologised and gave people support.

We saw evidence of significant events and complaints being discussed in the staff meeting minutes. We saw evidence that Medicines and Healthcare products Regulatory Agency (MHRA) alerts were shared with staff. However, we did not see evidence of a process to regularly review these safety alerts at meetings to identify learning and actions.

During our assessment we identified that there was no clear or consistent process in place for recording, reviewing or learning from triage‑related incidents. These included incidents linked to downtime of the online triage tool used for appointment booking, which limited the practice’s ability to identify risks, understand impact on patients and make improvements.

The practice 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 practice worked with other providers to deliver shared care when patients moved between services.

The practice processed referrals to other services in a timely way. The systems to identify and monitor delayed referrals worked effectively, including urgent referrals, such as those for possible cancers. Referrals and test results were managed in a timely way.

Staff knew who the lead for safeguarding was in the practice and would report any concerns. Information was available to support practice staff. 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 safeguarding lead had reviewed all patients who had been recorded on the clinical records system as being at risk of abuse or neglect and had up-to-date register of those who were still at risk of harm. There was appropriate alert on the clinical system for staff’s awareness and to help make sure the person was protected from avoidable harm.

The practice shared concerns quickly and appropriately. Staff knew how to identify, report and act when dealing with safeguarding concerns. They worked well with other healthcare professionals to ensure the concerns were addressed appropriately. There was a system in place for the management, oversight and reviewing of safeguarding concerns.

At our assessment site visit, there were identified training gaps, including incomplete safeguarding training (adult and child) and mental capacity training for clinical and non-clinical staff. Following our assessment, leaders confirmed all staff had completed the required level of training for their roles.

Safeguarding policies were in place and known to staff. The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations. The practice uses the London wide Urgent Care Plans system to document end of life care and complex patient situations. The use of the London-wide Urgent Care Plans system for documenting complex patient situations, including end of life care, is consistent with best practice and supports information sharing across agencies.

There was a chaperone system in place and training records showed all staff had received chaperone training. The practice displayed chaperone posters at reception areas and clinical rooms.

The practice kept all recommended medicines and equipment for use in an emergency and in line with their policy. Emergency medicines and equipment were in date. Emergency medicines and equipment were easily accessible and portable and weekly checks of the emergency medicines and equipment were carried out.

Staff had in date training for basic life support and sepsis. Staff could recognise a deteriorating patient and knew of action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

The practice told us parents of children who had not attended for childhood immunisations and people who had not attended for cervical screening, were followed up and further encouraged to attend.

The practice operated an online triage tool to help triage patient queries and appointment requests. The practice had guidance for staff to identify and escalate risk to an appropriate clinician. Patients who were digitally excluded or required additional support were assisted by front-line staff to ensure equitable access to care. Total triage was a standing agenda item within weekly clinical meetings. These meetings were used to discuss emerging issues, share learning, promote a consistent approach to communication and patient care.

At the time of our site visits, we did not see evidence that fire risk assessments had been completed for any of the three sites associated with this practice. Fire risk assessments were subsequently completed for all three sites following the CQC onsite visit with accompanying action plans outlining identified actions and timescales, as advised by an external fire safety assessor. Issues identified within the fire risk assessments included concerns regarding the effectiveness of fire doors, the absence of a valid fixed wire electrical safety certificate. The practice carried out regular fire drills, and all staff had been trained as fire marshals.

Staff were up to date with their health and safety training. We inspected the Control of Substances Hazardous to Health (COSHH) cupboard and found it was securely locked.

The practice had identified potential risks within the care environment, which were recorded in their infection prevention and control (IPC) audit. However, there was no evidence of interim measures being implemented to mitigate these risks while longer‑term actions were being discussed with the landlord.

There was a business continuity plan in place which was monitored and reviewed.

Learning needs and development of staff was not always managed appropriately. Although the provider used computer software to track mandatory staff training, some staff had not completed required training.

There were a range of clinical and non-clinical roles within the practice. The practice was unable to provide evidence that staff received effective clinical supervision, or that supervision arrangements were appropriately documented. We were not assured that all clinical staff received regular supervision and appropriate monitoring, or that supervision arrangements were consistently documented. While a clinical supervision policy was available for GP registrars, we did not see equivalent evidence for nursing staff. The practice was unable to provide evidence that all staff had completed mandatory training. This limited the practice oversight and assurance of staff competence.

There were clinical meetings, practice meetings, nurse meetings which staff told us were helpful. A review of five staff recruitment records found that three staff members had not received their annual appraisal within the required timeframe.

The practice was able to show evidence of new staff receiving an induction to the practice.

Leaders had not consistently followed their own recruitment check processes.During our inspection we reviewed a sample of 5 recruitment records and found that records kept by the practice did not contain all the required information. 4 out of 5 recruitment records did not include evidence of qualifications relevant to the staff members’ roles. In addition, recruitment records for one clinical staff member did not include an employment reference. Following our inspection, the relevant qualification and reference for staff was provided; however, the reference was signed and dated after the inspection date.

The service did not assess or manage the risk of infection effectively. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The practice had a designated infection, prevention and control lead and all staff had had relevant training. Cleaning schedules were in place and followed. Bins used for the disposal of sharps, such as needles and injections, were labelled correctly and used safely.

The practice had identified potential risks within the care environment, which were recorded in their infection prevention and control (IPC) audit. However, there was no evidence of interim measures being implemented to mitigate these risks while longer‑term actions were being discussed with the landlord.

We identified several environmental concerns that could impact safety and infection prevention and control. These included flooring in clinical areas lifting at the edges, walls in poor condition, mould growth and condensation were observed in some clinical rooms and the absence of a handwashing sink in the staff toilet, requiring staff to leave the room to wash their hands. Leaders told us they were in discussions with the landlord regarding the lease and necessary repairs; however, there was no interim measures in place to mitigate the identified IPC risks while these issues remained unresolved.

The practice had a staff immunisation policy. However, we found that this was not always being followed, and the practice had not always evidenced staff immunisations in line with UK Health Security Agency Guidance. The practice advised that they are in discussion with the Integrated Care Board (ICB) regarding how this can be managed more effectively going forward.

As part of our assessment a number of set clinical record searches were undertaken by a CQC GP specialist advisor. These searches were completed with the consent of the provider, to review if the practice was assessing and delivering care and treatment in line with current legislation, standards and evidence-based guidance.

We reviewed clinical records for patients who had been prescribed medicines which required monitoring. Our review showed that regularmedicines reviewswere carried out for people who used the practice to ensure their medicines were safe and appropriate to their needs. Patients are contacted and encouraged to attend medication reviews, and we saw that doses were reduced when patients are not engaging with monitoring. However, during our review of patients on polypharmacy (defined as more than 10 repeat medications), these reviews were not consistently documented in a structured format. In several cases, patients were coded as having received a medication review, but the clinical records did not clearly demonstrate what was discussed.

There was no evidence the person completing the medicine review had asked the patient about side-effects from their medicines, how they felt their medicines were working for them, or noted if the patient was taking their medicines as prescribed or had addressed any reasons if not.

During our clinical searches we reviewed medicines prescribed to treat insomnia and anxiety. A search identified 36 patients. A sample of five patient records was reviewed. All five reviewed records demonstrated appropriate clinical oversight, including discussion of the addictive nature of these medications and active attempts to reduce prescribing dosages.

We reviewed patients of childbearing age who had been prescribed medications known to carry risks during pregnancy. We looked at patients prescribed valproate; a search identified 2 patients. A sample of 2 patient records was reviewed. We found that there were no risk assessment forms stored within the patient's clinical record, and no evidence that risks had been communicated to patients in written format. This did not meet the requirements of the MHRA Valproate Pregnancy Prevention Program.

We looked at patients prescribed Topiramate for migraine, a search identified 1 patient. The patient record was reviewed; there was no evidence of a specialist risk assessment form having been completed by the neurologist at initiation. There was no annual risk acknowledgement on record, and no evidence of a specialist review confirming that the patient still required this medication, despite it being regularly issued. The practice did engage the patient by text and telephone regarding associated risks, but this does not fully meet the expected monitoring standard.

We looked at patients on carbamazepine (used to treat seizures, bipolar disorder, pain) and pregabalin (used to treat pain, seizures and anxiety); and found there was evidence that the practice appropriately communicated the risks these medicines can pose to an unborn baby, in line with current guidance.

We looked at people who were prescribed a Direct Oral Anticoagulants (DOAC), which is a type of medication prescribed to treat and prevent blood clots. The search revealed 15 patients who did not have a recorded creatinine clearance, a sample of 5 patient records was reviewed. There was evidence of the medication being issued without confirmation that creatinine clearance had been checked or that the prescribed dose was appropriate.

We saw evidence that Medicines and Healthcare products Regulatory Agency (MHRA) alerts were shared with staff. However, we did not see sufficient evidence to demonstrate that systematic searches in response to MHRA alerts were being undertaken consistently.

Medicines were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines, vaccines. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments.

The practice adhered a local antibiotic stewardship policy that measures the appropriate use of antibiotics and optimises the use of antibiotics to improve patient outcomes.