Merridale Medical Centre - RP Tew

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.At our last assessment, we rated this key question as Good. At this assessment, the rating remains the same.

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.

The practice had processes for staff to report incidents, near misses and safety events. The practice had a positive culture of safety and leaders encouraged staff to raise concerns when things went wrong. Staff felt there was an open culture, and that safety was a top priority. Patient feedback we received indicated patients felt supported to raise concerns.

Lessons were learnt to continually identify and embed good practice. Learning from incidents and complaints was discussed in meetings and resulted in changes that improved the service.

Leaders were committed to learning. We discussed an example of a significant event and the actions the practice had taken in response to the learning identified. This involved a patient who had stopped attending secondary care appointments and had been discharged from the secondary care clinic as a result. When discharged, the clinic had failed to inform the practice to discontinue the prescribing of Carbimazole (a drug used to treat an overactive thyroid) medicine. The practice realised this error as a result of identifying the patient’s monitoring was overdue. Staff raised a significant event and took action to undertake an audit of all patients prescribed this medicine. The patient was short-scripted (prescribed for a short term or a one-off) their medicine, monitoring was arranged, and the practice referred the patient back to the secondary care clinic.

The practice worked with patients and healthcare partners to establish and maintain safe systems of care. Staff worked to facilitate continuity of care, including when patients moved between services. There were protocols in place for managing incoming correspondence into patients’ medical records. Patient referrals to specialist services were documented in the referrals systems and patient record. We found referrals were managed in a timely manner.

Safeguarding policies and procedures were in place to keep people safe and safeguarded from abuse. The practice had two safeguarding leads, and staff had completed the relevant safeguarding training for their role and shared concerns quickly and appropriately. The practice maintained a list of vulnerable adults and children and acted on concerns working in partnership with other organisations. Clinical system alerts were used to identify people who were at risk of harm or abuse including household contacts. There were systems in place to respond to concerns and act on correspondence. For example, the practice followed up children who failed to attend their appointments or were frequent attenders to the accident and emergency department.

Regular monthly safeguarding meetings with the practice safeguarding leads and multidisciplinary healthcare professionals took place where safeguarding risks and patient care were discussed. Safeguarding was a standing agenda item for the monthly whole practice meetings to keep staff informed as appropriate.

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. There were processes in place to ensure care was prioritised for the most clinically vulnerable patients.

As part of our assessment, we checked the emergency equipment and medicines available and reviewed the processes to maintain these. We found the system in place to regularly check the emergency equipment and medicines needed to be improved. We identified some missing weeks when the emergency equipment and medicines had not been checked. This was escalated to leaders who made immediate arrangements to communicate this error with staff.

In addition, we found not all emergency medicines were available. Atropine (a drug which is used to counteract a slow heart rate that can sometimes be triggered by the pain or stress of coil fitting)was not available as part of the emergency medicines stock. We escalated this to leaders who made immediate arrangements to source this medicine and notified all staff that no coil fitting patient appointments were to take place until the medicine was stocked. In addition, the practice immediately developed a new protocol for staff advising on when to administer Atropine.

We also identified Glucagon (a drug used to treat very low blood sugar); Naloxone (a drug which rapidly reverses an opioid overdose); and antiemetics (drugs which prevent and treat nausea and vomiting) needed to be stocked. Leaders immediately acted on this feedback also and ordered these drugs whilst we were onsite at the practice.

The practice facilities were fully accessible to patients. The building was step-free for patients, with full access for wheelchair users. Consultation rooms were located on the ground floor.

The practice detected and controlled potential risks. They made sure equipment, facilities and technology supported the delivery of safe care. Contracts were in place to ensure the premises were maintained. Systems were in place for the checks of fire alarms, fire extinguishers and fire evacuation procedures. Portable appliance testing was completed annually to ensure equipment was safe to use. The practice provided us with evidence of health and safety risk assessments which showed that risks were properly managed. There was a business continuity plan in place which was monitored and reviewed.

The practice made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development.

There were a range of clinical and non-clinical roles within the practice. We found training was up to date, learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence.

For clinical staff the practice had established a Clinical Supervision policy which outlined responsibilities of the supervisors and supervisees. We discussed clinical supervision of Physicians Associates and leaders explained the Duty GP provided supervision and de-brief sessions where patient care was discussed. We saw evidence of the de-brief sessions booked in the practice appointment diary and examples of the documented de-briefs.

We also saw evidence of dedicated debrief time for Advanced Nurse Practitioners and Advanced Clinical Practitioners to utilise to discuss any patient cases they wanted guidance with.

Random auditing of patient consultation notes and prescriptions were also undertaken to provide assurance of appropriate clinical care.

The practice assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The practice had designated infection, prevention and control (IPC) leads and staff had completed relevant training. Risk assessments and audits were completed, and actions taken to mitigate risks. Clinical waste procedures were in place. The practice had effective oversight of the external cleaning company to ensure cleaning schedules were followed and cleanliness met the required standard.

As part of our assessment, we reviewed staff personnel files in relation to immunisation status. We identified there were some staff who had missing vaccination records for Hepatitis B and escalated this to leaders. Leaders took immediate action and informed us they would be updating these records and carrying out risk assessments.

The practice strived to make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved patients in planning, including when changes happened.

Staff involved patients in reviews of their medicines and helped them understand how to manage their medicines safely. Patients knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms.

Medicines were stored securely and at appropriate temperatures. Refrigerators used to store vaccines and medicines were monitored to ensure temperatures were maintained and products were appropriately stored within them.

We reviewed Patient Group Directions and Patient Specific Directions (written instructions to help specific healthcare professionals supply or administer medicines to patients). We found that some Patient Specific Directions (PSDs) were not appropriately authorised.We fed this back to the practice who took immediate action to rectify this. Leaders told us they had decided to change their processes immediately after our site visit to move to online PSDs in the patient record in place of paper PSD documentation. In addition, management created a new policy reflecting this change and we were provided with evidence of this policy and an urgent communication sent out to all staff to inform them of this change.

There was a programme of regular clinical audits of prescribing that focused on improving care and treatment. This included audits on antibiotics and hormone replacement therapy (drugs used to treat the menopause).

Prescribing data reviewed as part of our assessment found practice performance was in line with national averages for Pregabalin and Gabapentin medicines (primarily anticonvulsant drugs, also prescribed for pain); psychotropic medicines (used to treat various mental health conditions); and antibiotics. Our review of prescribing data for hypnotic drugs (used for the management of severe insomnia) however identified the practice was prescribing above the national averages for this medicine.

As part of our assessment a Care Quality Commission GP Specialist Advisor undertook searches of patient records on the practice’s clinical system. Our clinical records review identified the following:

Methotrexate (an immune system suppressant drug): We identified 42 patients prescribed this medicine in the last 6 months and reviewed a sample of 5 patient records. We found all 5 patients had received the required monitoring and were appropriately coded on the clinical system.

Amiodarone (a drug used to treat or prevent heart rhythm disorders): We identified 12 patients, and we reviewed the records of 5. We found 3 of these 5 patients had not received the required monitoring. This included blood tests for magnesium. Specialist Pharmacy Service guidance states magnesium blood testing is required every 6 months for patients prescribed this medicine. The practice immediately responded to our feedback in relation to this and updated their practice policy to include magnesium levels as part of their blood monitoring and reviewed all patients on Amiodarone medicine.

Gabapentinoids (drugs used to treat pain and seizures): We found 250 patients had been prescribed this medicine of which 45 patients had not received a review in the last 12 months. We reviewed the patient records of 5 of these patients and found 4 patients were overdue monitoring. As these are addictive medications, patients need to be reviewed regularly to ensure their correct compliance; avoidance of overuse; and monitoring of side effects. The practice took immediate action to address this issue, and the practice pharmacist was tasked with urgently reviewing all of these patients.

Short-acting beta-2 agonist (SABA) inhalers (“reliever" inhalers used for quick relief from asthma symptoms like wheezing and breathlessness): We identified 58 out of 1315 patients on the asthma register had been prescribed 2 or more courses of rescue steroids. We reviewed a sample of 5 patient records and found all 5 had received an adequate assessment at the time of the prescribing of rescue steroid. However, we found none of the 5 patients had been followed up to check their response to treatment in an appropriate timescale following the acute exacerbation of their asthma. National Institute for Health and Care Excellence (NICE) guidance recommends that patients receive a follow up within 48 hours. The practice took immediate action in response to our feedback in this area and all clinical staff were reminded of the NICE guidance and will now ensure that a 48-hour review is in place for all patients given oral steroids for an asthma exacerbation.

Safety Alerts: There was a process in place for recording and sharing medicine safety alerts. Safety alerts were discussed in clinical meetings. Our review of clinical records however indicated that safety alerts were not always actioned in line with guidance. For example, we identified 155 patients who had been prescribed an SGLT-2 inhibitor (a drug used to lower blood sugar). We reviewed a sample of 5 patient records. We found for 3 out of the 5 records, there was no evidence to demonstrate these patients had been made aware of the risks of diabetic ketoacidosis and Fournier’s gangrene associated with this medicine in accordance with national Medicines and Healthcare products Regulatory Agency (MHRA) drug safety alert guidance. The practice took immediate action to address this issue and updated their practice policy. Leaders told us, all patients on SGLT2 inhibitors will now be sent a leaflet detailing all the possible side effects they need to be aware of every 6 months, and this had been completed.

Medication reviews: We reviewed a random sample of 5 medication reviews out of a total of 588 reviews that had been completed for patients in the previous 3 months. We found 2 of these 5 medication reviews had been coded but lacked information, such as monitoring arrangements or details about what had been reviewed or changed as a result of the review. Staff took on board our feedback on this issue and recognised the importance of documentation for medication reviews.