Church Langley Medical Centre Also known as Dr M Kisenyi & Partners

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

At the last inspection in 2023, we rated the provider as Inadequate for providing safe services because safeguarding systems were not consistently implemented. We found gaps in monitoring and managing staff immunisations and storage of vaccines, risks to patient safety, infection control and learning and improvement when things went wrong. At this inspection, we found improvements had been made to some aspects of safe; however, further improvement is still required. Therefore, we rated the provider as Requires Improvement in how they provided safe services to patients. This was also linked to the need to improve governance.

This service scored 47 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There were inconsistencies and misunderstandings in communications between patients and the practice. We saw 2 complaints, raised by CQC during the assessment, where the practice had differing views to the outcome than the patient. For example, GPs told us a patient did not wish to raise a formal complaint and the patient shared they had raised a formal complaint that had not been addressed. Other complaints were not always addressed and responded to satisfactorily from the patients point of view.

Staff told us they recorded significant events, which would be reviewed by senior staff and followed up by the significant event lead. They then shared these with staff in the various practice monthly meetings and sent round via meeting minutes. Managers told us learning from incidents was linked to information sent to staff. However, at least 3 of the staff told us learning from incidents was not shared with them and they did not attend meetings where they were discussed. For example, some staff told us they were not really made aware of concerns and outcomes and did not receive an email. Some of the practice staff could not recall an example of significant events; therefore, we were not assured learning was being shared amongst all relevant staff. Some staff told us of an incident regarding a 2-week wait referral sent to a male patient for a female patient but were not told of the outcomes.

The pharmacy staff were responsible for reviewing all incoming patient safety alerts which they escalated to the practice manager. The practice manager told us these were shared with relevant staff.The Herts and West Essex Integrated Care Board (HWEICB) told us the practices patient safety alerts were consistently managed.

There was a significant event policy and we saw evidence of recording significant events using a (red, amber, green) RAG rated system and they were discussed in monthly meetings. Although we saw some evidence of identifying and reporting concerns, we were not assured of safe systems in place which demonstrated consistency and would promote learning. Although staff knew how to report incidents, they did not know how or when to report or notify CQC as required by regulation. For example, there had been 2 significant events which impacted patient's access to the service due to problems with telephone and computer systems. This was not recorded in their significant event records and a notification was not sent to CQC as per requirements relating to the disruption of normal service within a practice.

We looked at the practice’s significant event records since January 2024 and found 11 of 30 were the result of near miss incidents that could have led to patient harm. For example, there had been 4 recorded incidences of medicines errors relating to the administration of vaccines and when we reviewed them we found the ; for example, the 4 vaccine administration errors took place within the space of 1 month in October 2024 and involved extra administration of flu and shingles vaccines. The evidence provided by the practice showed changes had been made; however, we were not assured of an effective system put in place to monitor staff performance to ensure such incidents did not occur again and how learning had been shared with the rest of the clinicians to ensure learning was seen by all. Whilst these 4 vaccine related incidents did not lead to patient harm on this occasion, the practice did not demonstrate that any action had been taken to reduce the risk of harm to patients in the future. Opportunities to ensure learning and improved outcomes for patients were inconsistent. Senior leaders were unable to demonstrate reporting of these incidents around vaccination errors under the duty of candour, learning and or action taken to prevent a recurrence. However, we saw action to improve security of prescriptions following an incident. Meeting minutes from clinical, nurse and health care assistants (HCA), reception and administration meeting minutes did not show any significant events were discussed and were not part of the agenda. There was a system in place for receiving safety alerts via email and we saw evidence of a safety alerts log and action taken on safety alerts. However, monitoring was required to ensure all the relevant staff were aware of this process, as some clinicians were not clear on who would receive the incoming alerts and could not recall the most recent alerts in the practice.

We received a wide variety of feedback from people using the service, including internal and external survey results. The practice carried out their own internal patient survey in 2024 and sent out 2,500 invitations by text message. 564 patients responded to this survey and results showed 22% of patients thought their experience was very good at the practice and 9% thought their experience was very poor. The data for the 2024 National GP patient survey showed 65% of patients responded positively to the overall experience of their GP practice and this was comparable to the national average of 74%.Feedback sent to CQC showed whilst some patients were happy with the overall care and described an exceptional standard of care, some patients described a lack of continuity of care. For example, some patients experienced difficulty with being referred onto secondary services for wound care, whilst others had difficulties moving their care from other providers. Some patients told us young children were told to go to accident and emergency after they were refused appointments and other patients raised concerns about not being informed of their test results or having multiple blood tests taken without adequate explanation. One verified NHS review raised concerns about an incorrect referral that delayed them receiving care.

Staff told us they worked to support people moving between services and ensuring there was continuity of care when this happened. Staff responsible for arranging routine monitoring told us they requested and managed blood tests for patients requiring high risk medicines and made referrals to the district nurses for housebound patients where required. Staff also told us about improvements following changes made to their test result processes.

In September 2024, the Herts West Essex ICB (HWEICB) identified that there was an unacceptably high number of documents waiting to be scanned, coded and filed. As of 8 November 2024, there was in excess of 6400 documents some dating back to July 2024 and of this number, all had been reviewed using EZ-DOC protocol and any clinical actions required had been forwarded to the relevant person. The HWEICB stated at their visit on 11 September 2024 that the practice required mitigations in place to reduce the number of documents in the backlog. The practice had placed this on their risk register to review and mitigate.

There was a continuity of care policy as well as correspondence management policy which related to workflow process, test results, clinical correspondence and coding. However, we found some gaps in processes; for example, whilst it was identified that there was only one staff member designated the role of managing all the clinical correspondence, we were not assured of an effective oversight system as there had been concerns raised about the backlog of 6,400 unactioned clinical correspondence. At the time of inspection, the provider told us this issue was still a work in progress although a third party was employed to assist with the backlog temporarily; however, they had experienced some unforeseen delays. The practice recognised the challenges relating to the management of clinical correspondence and the impact this had on the designated staff member. At the time of inspection, they were implementing an action plan to cross train multiple staff at document management as well as recruit more staff. We viewed the outstanding test results on the practices clinical system and found they were up to date with 16 test results, 7 of which were abnormal test results dated 6 November 2024, a day before the inspection. There were some concerns with regards to urgent referrals and found there were 2 significant events relating to 2-week wait referrals. There was a risk to patients receiving timely care and treatment if documents had not been processed in a timely manner.

The practice had a referrals policy and a separate 2-week wait referrals policy. We found that although some referrals were managed appropriately, we were not assured the system in place ensured a consistent, safe approach. The policy was to send referrals via the electronic referral system (e-RS) and some as paper referrals. The 2-week wait referral forms were completed by a clinician then tasked to the secretary to be actioned within 24 hours. The patient was informed once the process was complete. However, we were not assured of an effective system in place to ensure they followed up patients when they had not received an appointment because the 2-week wait referral monitoring spreadsheet provided did not document if the patient had received their fast-track appointment, or if they had received an outcome following an appointment. There was no evidence of any audits in place to monitor this system. We also found the 2-week wait referral policy in the practice induction pack was overdue a review in 2022, yet the original policy submitted by the practice had been reviewed.

We did not receive people’s feedback in relation to safeguarding.

Staff could name their safeguarding leads and had access to the safeguarding policy. Leaders told us staff were aware of the procedures to be followed and how information was to be shared if abuse was suspected. They gave us examples of how a patient was safeguarded following concerns with a family member during their consultation. Staff felt safeguarding was something they did really well at the surgery as they had regular discussions around their safeguarding patients. Staff were aware of their individual responsibilities to share information and to engage with external agencies when requested.

Staff were able to identify at risk patients and their family members and were aware of the alert process and the requirement for action plans to be produced and acted upon in a timely manner. For example, non-clinical staff described how they raised a safeguarding alert following a home visit, although they weren’t informed of the outcome. Clinicians were invited to multi-agency safeguarding meetings and staff completed the appropriate level of training depending on their roles and responsibilities. Training was undertaken every 3 years with clinical staff completing their level 3 safeguarding training as per the requirements of their roles

There was no feedback received from external partners regarding safeguarding systems and processes at the practice.

The provider had the right systems and processes in place to make sure children and adults were protected from abuse and neglect and named safeguarding leads were in place. We saw innovative practice where the provider held quiz nights with staff 4 times a year, where safeguarding questions were included. There was a chaperone system in place and staff were chaperone trained. There was as process to follow up children who did not attend appointments. The provider had a child and adult safeguarding register in place; however, the information included did not show when the patients were last reviewed. Some staff we spoke to were not aware of how many patients were on these registers, so there was a risk that vulnerable patients were not identified and provided with safe care.Patients on the safeguarding register were reviewed at the monthly multidisciplinary team meetings and we saw evidence of discussions. The clinical and non-clinical safeguarding lead ran safeguarding reports and held regular weekly meetings until all patients had been reviewed and recorded. We reviewed the meeting records for 2 October 2024 where they found 210 adult and 374 children safeguarding patients were to be reviewed; however, only 5 were reviewed and recorded at a time. A social services representative attended their MDT meetings to provide support if required.

The safeguarding policy we viewed listed the relevant contact details and responsibilities for all staff groups. However, we did not see how the practice shared safeguarding information with the out of hours service. There was a duty of candour policy. We observed through multidisciplinary meeting minutes that clinicians had a clear understanding of the Deprivation of Liberty Safeguards (DoLS) and this was only used when it is in the best interest of the person. Job applicants at the practice were required to undergo either an enhanced or standard DBS check depending on the position applied for. We also reviewed 5 staff DBS records and found all the staff had a DBS certificate.

We received patient concerns that a clinician had missed sepsis red flags that led to hospital admission. Several other patients did not feel their care needs were met in a way that was safe. For example, CQC received a significant amount of feedback in relation to missed diagnoses that led to deterioration in conditions. We also found this was consistent with some of the complaints directly sent to the practice around the same themes where patients felt they were placed in harm’s way due to red flag symptoms being missed.At the time of inspection, the Herts and West Essex integrated care board (HWEICB) had received 1 complaint against the practice related to clinical treatment.

Leaders told us sepsis training was carried out annually and considered mandatory and all staff were up to date with this training. There was an acutely unwell under 5’s guidance document which was a referenced document on how the practice would manage the acutely unwell child, including suspected sepsis. Staff told us they had the equipment required to perform their roles. Staff were aware of actions to take if they encountered a deteriorating patient; however, not all staff we spoke to were aware of the red-flag symptoms of sepsis. There was a risk that these patients would not receive timely emergency treatment due to staff not being aware of red flag symptoms.

When we reviewed their processes we found they held a whole practice risk register that was regularly reviewed and constantly updated as it was a working document. Clinical and organisational risk was identified on this risk register. We saw all staff were up to date with their sepsis awareness training, with 4 of the staff due update training in the following month. However, when we spoke to staff, not all of them were able to describe the red flag symptoms for sepsis but they were aware of the posters around the practice. The practice held appropriate emergency medicines and risk assessments were in place to determine the range of medicines held. There was oxygen and a defibrillator and staff were able to demonstrate the use of this emergency equipment.

There was an effective approach to managing staff absences and busy periods. The provider had a risk register in place that reviewed the organisational, clinical and financial risk to the practice. They were equipped to respond to medical emergencies and staff were suitably trained in emergency procedures such as basic life support. The practice held appropriate emergency medicines and risk assessments were in place to determine the range of medicines held. Nursing staff carried out weekly checks of the emergency medicines and defibrillator, whilst the oxygen was checked twice a week. There was also other equipment available such as nebulisers and pulse oximeters and checks were in place for them to ensure they were working as they should.

There was an emergency call button and we observed a quick response from all the staff when this was tested on inspection.The emergency medicines were stored inside a locked cabinet in a locked clinical room and the oxygen was also stored inside a locked clinical room. However, the practice could not assure themselves that these would be easily accessible in an emergency to provide timely lifesaving treatment, as a risk assessment had not been completed to determine this was the most appropriate way to store the emergency medicines and oxygen.

Staff told us they had the equipment they required to perform their roles and they were satisfied with the health and safety arrangements in the practice. Staff told us the fire alarm was tested once a week and fire drills took place with the last one being 6 months ago. Staff we spoke with were aware of the fire marshals in the practice and we observed the designated marshals sit with their high vis jackets ready at the back of their chairs.

The practice building was owned by Harlow Community care. The practice was hoping to extend the premises and the discussions were ongoing at the time of the inspection. The building was established in 1996 and was located over 2 floors in a purpose-built building that provided the required facilities such as disabled access. We observed a clean waiting area, which was warm and furnished appropriately. Leaders told us premises space was a challenge for the practice. The practice had access to 9 clinical rooms and were due to extend their contract with the landlord in 2 years' time. There was enough space for people to move around and decoration was in good order. We saw evidence taken by the provider to maintain the security of the premises. On inspection we observed the practice had taken steps to make the designated fire marshals visible in the practice. The 6 designated fire marshals had also received onsite training from an external service in September 2024. The practice provided their friends and family test survey results for May 2024, which highlighted that patients were very happy with the upgrade to the practice and felt it was much more presentable.

The practice had effective arrangements to monitor the safety and upkeep of the premises. Fire equipment testing was carried out in September 2023 and fire alarm testing was carried out every 6 weeks. The practice had effective measures in place to ensure fire drills took place and where they failed a fire drill, we saw that fire marshals reviewed what went wrong and how further drills could improve the process of safe evacuation.When we reviewed training records, we saw that staff were up to date with their fire safety training and some staff had received fire warden training. Annual health and safety, fire and disability risk assessments were carried out and the most recent one was carried out in November 2023 and due in November 2024. Portable Appliance Testing (PAT) was carried out and in date. The practice also maintained their security systems. The practice provided a water tank inspection report; however, we did not see evidence of a legionella risk assessment or equipment calibration records.

The disability risk assessment determined the risk of anyone with disabilities being injured while onsite as low. The recommended actions from this assessment were for colour contrast to be improved between handrails, grab rails and walls. The fire risk assessment determined high to low risk. The actions of high risk required the practice to take immediate action to inspect all structural fire protection and elements of fire compartmentation annually. Other medium risk identified was to fit all fire-resisting doors with appropriate self-closing devices and discourage the use of portable heaters. We were not provided with evidence to show a plan to address this.

The health and safety risk assessment identified low risk in relation to ensuring the health and safety poster was completed correctly. However, further action was required to ensure all the risk assessment reports were signed upon receipt as required to validate them and to ensure the recommended action plans were documented on the risk assessment to ensure completion, as we did not find this on inspection. We observed up to date emergency lighting certification and weekly fire alarm testing records. An electrical installation report showed they were in satisfactory condition at the time of testing, with areas of recommended improvement; for example, residual current device (RCD) recommended protection which was a safety feature that automatically turned off electricity when an electrical fault was detected.

We received mixed feedback from people regarding their experiences with staffing. People who shared their experience of staff at the practice with us felt doctors were knowledgeable; however, some patients felt some of the staff did not know or follow practice policies and other patients raised concerns about inexperienced staff who had potentially given poor advice.

Feedback received from the Hertfordshire and West Essex Integrated Care Board (HWEICB) stated that workforce levels for direct patient care, nurses and GP were below average for the West Essex and national levels for numbers of staff per 100,000 patients; however, staff felt there were adequate staffing levels to provide safe care and treatment. Leaders told us they reviewed how many staff they required on a yearly basis and felt their nursing staff levels were good and had much improved since the last inspection. Nursing staff were satisfied with their numbers and felt there were enough of them to provide safe care to patients. They told us that during busy times such as winter pressures, they allowed for additional clinical staff at the practice to help with the additional rise in calls. There was staff cover for absence and staff leave was planned in a way that minimised disruption to patient care. For example, if phlebotomy services were required, there were enough trained staff to cover these clinics and appointments for medication reviews were re-booked.

The team had growing skills and there was a good mix of ability with staff with a variety of special interests. Several staff were being supported with professional development; for example, one healthcare assistant was being supported to undergo their nurse training and another staff member was completing university to receive accreditation as a GP Assistant. A phlebotomist was upskilled and received their care certificate training to become a healthcare assistant. Nursing staff felt leaders were very supportive in helping them to find peer groups in order to support their learning and lead GPs and nurses mentored and shadowed staff to confirm their competency. Staff told us they were up to date with their mandatory training and felt they had lots of training opportunities and access to external training provided by the ICB. Some junior clinicians felt there could be more training provided relating to hypertension and diabetes. Staff described their induction process and all staff told us they were up to date with their appraisals and we saw that one clinician was promoted to a lead role following their appraisal. The practice had access to locum and bank staff if required and a locum pack was stored on the system. They had access to a locum GP and leaders told us they ideally wanted to recruit more salaried GPs.

The provider had a wide variety of staff including ARRS staff and PCN staff; for example, a pharmacist and a paramedic working 2 days a week at the practice and we saw evidence of supervision for these staff members. There was a designated person in a day-to-day management capacity based at the practice and a designated senior on site. We observed different staff on the day of inspection and saw sufficient staffing levels to meet patient demand. We saw staff were commended in the practice newsletter when they completed notable training, such as The Oliver MacGowan training that had been completed by 95% of the staff. The practice had closure afternoons to facilitate staff training. Nursing registration was up to date and they received the support they required to revalidate as per their registration requirements. They attended regular course updates and provided certificates of competency before they were added to the surgery skills set. There were systems in place to supervise clinical staff. One pharmacist was going to be supervised by the lead GP whilst undergoing their university prescribing course; however, there were no current and formal supervision arrangements for this clinician at the time of the inspection. The provider told us this would be put in place going forward.

However, we were not assured of effective management of poor performance and not assured that learning was maximised to ensure staff had opportunities to learn from any mistakes. For example, information we reviewed from various records showed at least 8 missed diagnoses occurred and concerns around staff knowledge of undertaking wound care activities. One staff member felt they had not been trained for their role and we were not assured that staff involved in significant events received a review of their training needs to ensure repeated errors in diagnosis and treatment were not occurring consistently and placing patients at risk of harm.

When we reviewed staff recruitment records, we found there were gaps in 5 of the records we viewed; for example, there was only 1, not the required 2 references in all 5 files. There was no DBS on file for one staff member. Four of the 5 recruitment records we viewed had completed induction checklist on file. We were not assured that locum staff were being provided with accurate, up to date information to ensure they provided safe care and treatment to patients due to outdated information in their induction pack. The induction policy and checklist contained out of date information. For example, the 2-week wait referral policy included was overdue for review since 2022 and had not been updated. We also found the controlled drugs policy in this pack was due a review in December 2023 and not updated We reviewed appraisal records and we found one member of the staff member was overdue their appraisal since March 2023.

We received feedback from patients regarding observed infection control practices. Some patients' complained that some clinicians did not wash their hands prior to undertaking wound care activities. Practice policy was for hand gel to be used if hands were not visibly dirty and we saw this was fedback to the patient in their complaint response.

There was evidence of some IPC systems in place; for example, there was a protocol in place for patients with infectious diseases. The arrangements for managing waste and clinical specimens kept people safe. The arrangements for Control of Substances Hazardous to Health (COSHH) kept people safe. There was an Infection Prevention and Control (IPC) lead, who told us their IPC score had improved to 97% from their previous score of 72%. Staff told us their annual training was up to date and training records were consistent with this. Where training was due, leaders had highlighted the dates due on their training record.The infection control lead told us they carried out monthly handwashing and quarterly PPE audits and completed audit action plans which were reviewed by the practice manager. Practice equipment such as doppler machines, spirometer and ear irrigators were cleaned according to the infection control handbook and cleaning records were kept. Clinical staff told us they followed infection control cleaning procedures after each session and signed cleaning records in their rooms and we saw evidence of this.

As part of their IPC improvements since 2022, the practice carried out major works in the practice. Changes made included removal of all carpets from clinical rooms as identified in the previous infection control audit. There was a total re-fit to the communal toilets and the waiting area. New ceiling and lights were added to the reception area and vinyl flooring was placed in the GP’s rooms, corridor and all clinical rooms. Wall units were mounted for hand sanitisers in all clinical areas and wall mounts were placed in the kitchen area for drying of mops. The minor ops room had a re-fit where they removed 2 sinks and replaced them with 1 IPC compliant sink unit and improvements were made to the practice main office. The practice also had hired a new cleaning company. Mixer taps were also placed in clinical rooms and curtains were replaced. Monthly handwashing audits for the clinicians took place and they showed evidence of full compliance with the hand hygiene policy.

There was evidence of some IPC systems in place; for example, there was a protocol in place for patients with infectious diseases. The arrangements for managing waste and clinical specimens kept people safe. The arrangements for Control of Substances Hazardous to Health (COSHH) kept people safe. However, further improvements were required as whilst we observed the practice premises were overall clean, there were a few areas which needed attention which could pose an infection control risk. for example, clinical waste bags were not labelled, one of the toilets did not have a mixer tap and required a warning label due to its scalding water risk and cleaning mops were stored incorrectly. When we reviewed their vaccines stock sheets, clear dating and signing was required for each individual stock received for September 2024, as not all were signed for. The infection control lead completed an audit in October 2024 but the infection control monitoring completion dates were not inputted.

We received patient feedback as part of this inspection. One patient told us when they had medication queries, the prescription clerk was friendly, understood their issue and was very helpful. Other patients told us they always receive their medications quickly whenever they asked and admin staff were always efficient and professional. However, some patients told us that the practice did not listen to their concerns when they queried prescribed medicines dosages and the likelihood of adverse side effects.

The pharmacy staff carried out medicines reviews, including high risk medicines. Pharmacy staff told us repeat dispensing of medicines was now in place and this reduced staff workload. They told us patients who were compliant with attending their annual blood test monitoring and compliant with their medicines had them re-authorised.Prior to the inspection, the Herts and West Essex Integrated Care Board (HWEICB) shared information with us regarding medicines optimisation in the practice. They told us the practice engaged well with the Pharmacy Medicines Optimisation Team (PMOT) and had achieved on the local quality indicators for 2023 and 2024 to reduce their high dose inhaled corticosteroid prescribing and reduce co-prescribing of dependence forming medicines. Broad spectrum antimicrobial prescribing rates had also fallen in 2023/2024 and broad-spectrum prescribing remained significantly below the national target. Medicines safety alerts were consistently managed.

The practice held appropriate emergency medicines, risk assessments were in place to determine the range of medicines held and a system was in place to monitor stock levels and expiry dates. However, we observed emergency medicines were locked in a cupboard inside a keypad locked room; therefore, there was a risk of delay to treatment in an emergency. Assurances were required to ensure patients requiring emergency medicines were not delayed with this treatment due to the locked medicines.

We saw structured medicines reviews for patients with long term conditions and repeat medicines and saw examples of templates used for specific conditions. We observed a very good level of detail included by the pharmacist. Staff had the appropriate authorisations to administer medicines, including Patient Group Directions (PGD) or Patient Specific Directions (PSD). Nursing staff received contraception training and they were able to describe the process of administering contraceptive medicines; however, they were not aware of the red flags to look out for; therefore, there was a risk that they would not be able to identify if a patient was experiencing adverse reaction from the medicines that required urgent medical attention.

The practice had systems and processes in place for the appropriate and safe use of medicines; however, found some gaps in medicines management. There was a repeat prescription policy in place; however, this policy was out of date Despite pharmacy staff carrying out opioid reviews, there was no information regarding how they could access the Controlled Drugs Accountable Officer (CDAO) in this policy. The embedded polices within the repeat prescribing policy such as the medication change flowchart were also out of date and overdue a review since March 2022.

We identified 380 patients who had received a medicines review in the past 3 months and when we reviewed 5 of these records, we did not find any issues with monitoring. When we carried out our clinical records review for the management of Disease Modifying Antirheumatic Drugs (DMARDs) such as Azathioprine and found 2 of the records we reviewed showed patients had received the required monitoring as per the recommended guidelines. However, gaps were found when our clinical record searches found 10 out of 177 patients prescribed gabapentinoids had not received a review in last 12 months. We reviewed 5 of these records and found 4 patients were overdue a medicine or dose review and one of these patients was not informed of their of pregnancy associated risks. A lack of timely reviews placed these patients at risk of deterioration.

Our clinical searches also identified 18 of 1109 patients prescribed Ace inhibitors to treat heart failure and high blood pressure, had not received the required monitoring. A review of 5 clinical records showed monitoring was overdue for 4 of these patients. It is important to manage this as there could be a risk of unnoticed kidney damage.

There were 3 vaccines fridges in the practice. Nursing staff were responsible for cold chain monitoring and the fridge temperatures were checked twice a day as per national guidelines. Vaccines were appropriately stored, monitored and transported in line with UKHSA guidance to ensure they remained safe and effective and stock levels were checked weekly by the nurse. We saw evidence of the fridge manufacturer being contacted by the practice on 2 occasions following a cold chain breach; however, monitoring was required to ensure all cold chain breaches were being captured as significant events. We found there was a cold chain breach on one fridge on 1 November 2024; however, this had not been recorded as a significant event. The records also showed there were no staff signatures on both fridge 1 and 3 records to confirm temperatures had been checked.

There was a process for polypharmacy where administration staff would run a report for patients prescribed 8 or more medicines and the practice pharmacist would contact these patients and carry out face to face or telephone reviews. Routine searches were carried out for the review of antimicrobial prescribing.

Following our remote clinical record searches, the practice took immediate steps and submitted and action plan detailing follow up contact with the patients identified as not up to date with their medicines monitoring. For example, 18 patients prescribed ACE inhibitors either had their dosages reduced until they attended for monitoring or had their blood tests booked. Ten of the 177 patients prescribed gabapentinioids were booked in for appointments following the inspection.

There was a system for recording and acting on safety alerts. We saw evidence of several 2-cycle audits based on the patient safety alerts. For example, they carried out an audit on sodium valproate for male patients in response to the MHRA safety alerts. They also acted on the SGLT-2 inhibitor medicine (used for type two diabetes) that advised clinicians to discuss with patients about the risk of gangrene. Our clinical searches identified 148 patients prescribed this medicine and we reviewed 5 of these records and found the patients had been informed of the risks as per national prescribing requirements.