East Harling & Kenninghall 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

This means we looked for evidence there was a culture of openness in which there was a willingness to identify and learn from safety events. We looked for evidence people were protected from abuse and avoidable harm.

At our last inspection we rated this key question Good. At this inspection, the rating has changed to Requires Improvement.

This is because the practice did not always provide care in a way that kept patients safe and protected from avoidable harm.

The service did not have an embedded learning culture. People could raise concerns, but these were not always addressed in line with policy. People were not always protected and kept safe. The facilities did not always meet the needs of people using the service and staff. There were not always enough staff with the right skills, qualifications and experience to deliver care. Managers made sure staff received training, but we did not see evidence of ongoing appraisal and development in all areas.

However, dispensary staff managed medicines well and involved people in planning any changes.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We reviewed patient experience feedback sent to CQC, online feedback, complaints and significant event records. In addition, we also reviewed feedback provided through the Patient Participation Group (PPG) and local care home.

The information we reviewed and the patients we spoke with demonstrated that people had opportunities to provide feedback to the practice and were aware of how to make a complaint.

We heard from patients that not all concerns and complaints were responded to in line with the practice policies. Learning was not always shared with patients.

From our staff questionnaire feedback, some staff told us that they had received enough specific training for their role. However, some other staff told us that they felt they did not receive enough training and that there was not enough opportunity for further/ongoing development. Some staff told us that they were not provided with enough guidance, written procedures and/or policies to perform their role. We found limited evidence that learning was shared to mitigate future risks.

There was inconsistency with the sharing of learning from complaints and significant events. Some staff told us that learning was only shared if they were involved.

The practice had moved to recording significant events and complaints on a nationally recognised system following the appointment of a new practice manager. This allowed greater auditing visibility and tracking of complaints. The provider had a complaints policy; however it was not specific to the practice and the details stated, 'insert practice name here'. The policy also did not specify how they were going to share learning. There was a significant event policy which stated that staff would be involved in learning but did not outline about how it would be achieved.

The provider kept a clear staff training record and had good oversight of e-learning. However, it was unclear why learning was assigned to staff groups as there was no training needs analysis. Leaders confirmed that this was not in place.

We reviewed the providers significant events from the last 12 months.

We spoke with staff during the assessment who described systems to manage tasks relating to hospital discharge summaries. Leaders were working with the primary care network pharmacy team to improve the effectiveness of this system.

The practice implemented a waiting list system in March 2024 following feedback from staff and patients that the previous system did not meet patient needs. The practice told us that previously, the appointments had been fully booked within 5-10 minutes of the phone lines opening. Staff and leaders told us that they had seen a dramatic improvement to the appointment availability since the waiting list was implemented.

Staff were able to identify the safeguarding lead during our assessment. Staff described their individual roles in ensuring patients, including vulnerable adults and children, were followed up if they failed to attend appointments. Not all staff attended meetings where safeguarding cases were reviewed. There were minutes available for staff to review however some staff told us they did not have access to the minutes.

Leaders we spoke with described how the practice monitored and maintained oversight of safeguarding training and processes. Leaders told us safeguarding concerns were discussed regularly and was a standing agenda item, and as a small practice any concerns would also be discussed immediately.

We saw evidence of practice meetings where safeguarding concerns were discussed. Staff we spoke to who chaperoned patients were aware of female genital mutilation (FGM).

We saw evidence that there had previously been regular discussions between the practice and other health and social care professionals such as health visitors, school nurses, community midwives and social workers to support and protect adults and children at risk of significant harm. These had not occurred for a few months due to external constraints. The practice told us that they were trying to reintroduce regular multidisciplinary meetings. Following the on-site visit we saw evidence that a meeting had taken place.

We reviewed staff recruitment files and found that appropriate DBS checks had been completed. There was a clear system in place and the practice also had appropriate oversight of locum staff.

The practice had a policy with useful contact numbers and other sources of support.

Leads roles and contacts were displayed in every consultation room and reception area.

Safeguarding was a standard agenda item at practice meetings and incidents of concerns observed by staff were discussed. Leaders led discussions and learning from safeguarding incidents.

Chaperone processes were in place, and we saw chaperone posters displayed in clinical and reception areas. Staff could clearly explain their role and had undergone training at the appropriate level of their role.

41 members of the public told us that they had experienced delayed referrals or missed episodes of care. We were told that this had resulted in some people accessing private healthcare. This feedback was consistent with data from our stakeholders, people had told 'Healthwatch' that there were delays and barriers to care and that some patients were unable to get the advice and support required to manage their illness. Feedback from people during our on-site assessment was positive overall, and patients told us that there had been recent improvements to help them access care.

Care home representatives told us that a clinician visited the service on a regular basis to review patients as necessary. They also told us that changes had been made to improve communication, and direct contact was now available if a request was made outside of the planned visit times.

During our assessment we saw that the practice had made efforts to involve people to manage risks. The practice had a duty doctor system where patients with urgent needs were triaged and responded to as appropriate.

The practice had recently developed a waiting list system to improve the management of appointment requests. Patients were now able to be added to a waiting list for long term condition reviews, immunisations and health screenings and were contacted when an appointment was available. Data that the practice collected to monitor outcomes for patients showed that there had been an improvement in unanswered phone calls between February 2024 and June 2024.

Leaders told us they ensured health and safety risk assessments were conducted and appropriate action taken. We saw risk assessments had taken place but that some actions had not been completed. Leaders provided assurances following the inspection that updated action plans were in place.

The practice told us they had significant challenges in delivering care due to constraints within the buildings. The practice had an action plan in place to address these issues going forward. Dispensary staff told us that their working space was restricted but the practice had made adaptations where possible.

We looked at the practice documentation relating to health and safety during our assessment. We saw a range of audits, some of which had identified ongoing actions. We discussed this with leaders who confirmed this was an area for improvement. We carried out checks within clinical rooms on both sites to confirm the practice maintained appropriate equipment availability and safety, medicines storage, and waste management.

The practice was generally clean and well-organised. We saw appropriate audit and monitoring of cleaning schedules.

We saw evidence that actions raised in previous audits regarding legionella had not yet been completed. Recent improvements to audit processes had not yet fully embedded and the practice were continuing to review these.

Patients and patient representatives raised concerns about the staffing levels at the practice directly to us and via stakeholders. 14 people raised concerns to us about the retention and recruitment of staff, 23 people expressed concerns about the visibility of the GP partners. We received mixed feedback about the attitude of staff; 57 people had a negative experience and 108 people provided positive feedback.

We spoke with a representative from the Patient Participation Group (PPG) who told us that issues raised with them are primarily: access, lack of clinical capacity, visibility of partners, lack of consistency in clinical staff (significant turnover) and a need to have alternative means of communication with an older less digital population.

Care home representatives highlighted concerns regarding the consistency and number of doctors and were unsure if the GP partners still worked at the practice.

Staff told us that there were not enough staff to provide safe, high-quality care.

The practice had identified that they did not have the resource to provide appointments immediately and they had created a waiting list system to triage patients and manage workload. There had been some feedback that this had started to improve access.

Leaders told us clinical capacity for GPs was not at the level they would want. We saw that sessions were delivered almost entirely by locum staff. A salaried GP and permanent locum had been newly recruited although they had not started at the time of inspection and there were ongoing plans to recruit more GPs and non-clinical staff.

Some staff told us they were not aware of who the lead for infection prevention and control (IPC) was but had no concerns about the IPC processes. Policies were in place but these had not been updated with the practice details.

Staff told us there were systems in place for dealing with specimens and bodily fluid spills.

Appropriate standards of cleanliness and hygiene were met and most staff had received training.

The practice had a process of recording the vaccination status of staff in line with current UK Health and Security Agency (UKHSA) guidance if relevant to their role. However, we found that this process had not been applied to all the relevant staff members.

Feedback we received from patients was mostly positive in respect of the cleanliness of the environment.

During our on-site visit we found inconsistencies with the practice's IPC processes. Audit processes were in place but there were elements that could be improved for full assurance.

We found some areas of the practice that needed maintenance. We found a dirty fan located in a clinical room. The provider removed this once we alerted them and discussed how this could be avoided in the future.

Pharmacy staff provided a dispensing service for patients at both the East Harling and Kenninghall sites.

People had access to the dispensary team and were able to get their medicines from 8.30 to 1pm and 2pm to 6pm five days a week.

People could order their repeat medicines in variety of ways and turnaround times were within 5 working days.

Some people who required extra help with their medicines had them supplied in monitored dosage systems (MDS or also known as blister packs). A delivery service was available to those people who could not collect their medicines.

People receiving some skin preparations were not provided with the information leaflet making them aware of the actions necessary to reduce the flammable risk. Following the inspection the provider told us they had made changes in response to our feedback.

Emergency steroid cards were not provided to patients who were taking regular steroids in line with national guidance.

Pharmacy staff were involved in regular meetings and felt informed. Pharmacy staff found colleagues supportive and approachable. Pharmacy staff reported incidents and near misses. These were discussed regularly, and learning took place.

The dispensary space at East Harling was compromised. The space was too small and therefore activities spilt out into a corridor area behind the dispensary which was a challenging working environment for staff. The team were very well organised and ensured the security and safety was not compromised but it resulted in difficult working conditions.

Staff told us that their working space was the biggest challenge. The practice was pursuing plans for an extension to the current space.

Only authorised people had access to medicines at the practice. Medicines stocks were managed well, expiry dates checked, and appropriate checks of the dispensing process were in place. Emergency medicines were available and checked regularly. Medicines requiring cold storage were stored, monitored, and transported appropriately. Controlled drugs were appropriately stored and checked regularly. Blank prescription forms (FP10s) were stored securely with restricted access but were not recorded adequately so the service would not be able to tell if any were missing. The practice responded to this following feedback and had updated their policy to prevent this.

Patient Group Directions (PGDs) were in place to allow nurses to give vaccinations without a prescription and these had been appropriately authorised for use within the service.

Standard Operating procedures were in place for all the dispensary activities.

There was a duty GP every weekday to deal with urgent prescription issues.

The dispensary team undertook Dispensing Review of Use of Medication (DRUM) reviews which highlighted when people were no longer taking their medicines and this information was communicated to a clinician for review.

The practice had a system for recording and acting on drug recalls but not all safety alerts had been actioned such as the flammable risk with certain creams and the issuing of emergency steroid cards.

The process to ensure that all medicines prescribed, regardless of who supplied, them was recorded on the shared care record was not consistently applied.

When people were discharged from hospital the processing of the information in the discharge letter was outsourced to the Primary Care Network pharmacists (PCN) pharmacists. There was no written feedback provided to the practice about the turnaround times to process this information, although pharmacists processed those that had been flagged as urgent first. In the meantime, patients could potentially order repeat medicines that were no longer appropriate.

The templates for annual medication reviews were not always being consistently used therefore monitoring whether reviews have been completed was difficult for the service.

Staff at the practice told us that searches of the electronic system to ensure the safe monitoring of medicines were conducted by the supporting pharmacists from the PCN, however the PCN pharmacy team told us they are not involved in providing any support to run searches or audits.

The practice belonged to the Dispensary Services Quality Scheme (DSQS) and completed annual audits as part of this. The most recent audit ensured that medicines that were supplied in monitored dosage systems (MDS) were appropriate to be packaged in this way. Changes were made following this audit as some medicines were found not to be suitable to be included in the MDS.

We were made aware of a couple of significant events relating to cold chain breaches. Significant events were raised and learning had been shared. Data loggers had been implemented after these cold chain breaches.