Tottenham Health Centre

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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 assessed all 8 quality statements from this key question. Our rating for this key question is requires improvement. We found that the service was not always providing safe care because the provider did not keep up to date with best-practice guidelines in the monitoring and administration of high-risk medicines. Clinical records did not meet professional standards and the electronic record keeping system did not provide sufficient oversight of patient risk or potential diagnosis of a long-term condition. In addition, the practice had not carried out any recent and appropriate health and safety and fire risk assessments. The practice also failed to ensure appropriate supervision and processes for the administration of vaccines administered by the health care assistant. We found that there was an ineffective system in place for the storage, monitoring and allocation of blank prescription pads.

However, the provider was responsive and took immediate action to address the above concerns and introduced systems and processes to prevent re-occurrence. We rated the service as Requires improvement for this key question, as these changes need to be monitored and become embedded in practice.

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.

Patients knew how to complain and who to complain to. There was information on the practice website and visible complaints procedure displayed in the practice for those who were digitally excluded. Members of the Patient Participation Group felt the practice was continually improving and acted on feedback. For example, one member told us that they had suggested a water fountain in the reception area, and the practice acted on this feedback and had one installed.

The practice manager handled non-clinical complaints, and the GP partners led on clinical complaints. The practice had received three formal complaints in the last twelve months. All complaints were handled according to practice’s complaints policy. Staff said team meetings were regularly conducted with the minutes recorded and shared.

There was a log of complaints, significant events actions taken, and lessons learned. There was a clear process for reporting, investigating and learning from significant events and complaints. The practice manager and a GP partner showed us complaints and incident policies including significant event policies. There was a clear demonstration of how the practice handled events and complaints and the lessons learned with the action plan drawn up to prevent recurrence.

Staff understood their responsibilities to process routine referrals. Staff also understood their responsibilities to manage urgent cancer referrals and follow these up to ensure patients had attended their appointments within the two-week wait period.

The GP partner recognised that there were shortfalls in their systems and processes. The GP partner told us that the practice required more managerial staff, both clinical and non-clinical. We were provided with evidence that the practice was actively pursuing a merger with a local practice. We received feedback from the ICB that a merger would be highly beneficial for the practice, and that the matter is currently under review.

Clinicians could not demonstrate complete oversight of the monitoring of people with long-term conditions including people’s medicine reviews. Following the assessment and clinical searches, leaders provided an analysis and plan to mitigate the risks identified and make required improvement to ensure effective oversight.

We found blank prescription pads in unlocked drawers behind the reception area. The door to the reception area was also kept open and unlocked even when unattended. Staff we spoke to said that prescriptions were handed out to clinicians on request, and there was no system to log to whom the prescriptions had been allocated. This poses the risk of prescription pads going missing and being unlawfully used by staff and patients. After the inspection, we were told that blank prescription pads were now secured in a locked cupboard, and the allocation of prescriptions were noted on a spreadsheet.

Staff acknowledged safeguarding concerns for the three patients identified by the ICB were not managed well. As a result, we were told there was large emphasis on safeguarding processes and training during the summer of this year. During our interviews staff could explain how safeguarding concerns were recognised and how they would be reported. Staff knew who the safeguarding leads were for adult and children.

We received concerns from the ICB regarding three safeguarding cases. During the inspection and clinical searches, we identified these cases and found appropriate referrals and follow up appointments for all three patients were not carried out in a timely manner. However, we were satisfied the patients were presently not at risk, as the correct measures and actions had been put in place to protect those patients. The partners told us that the ICB did raise concerns, and the practice acknowledged at that time their safeguarding processes were not up to standard. As result of these three cases, the practice carried out significant event analysis on their safeguarding systems and processes, which resulted in action and learning.

Due to the safeguarding concerns mentioned above the practice had renewed their safeguarding policies and procedures. All staff had also undergone safeguarding training appropriate to their role. The reception area, and all clinical rooms all had safeguarding posters printed on the walls, which included all appropriate information. We also saw evidence of recent safeguarding referrals which were handled and actioned appropriately. The practice also evidenced that they regularly discussed safeguarding concerns during their internal team meetings and external multi-disciplinary team meetings.

Patients felt they were involved in their care and treatment. Results from the national GP Patient Survey for questions relating to patients being involved in their care, showed that the practice was in line with, or above the national and local averages.

Staff understood the role of involving people in making decisions about their care and treatment. Risks were identified and discussed with people and documented in the patient records such as do not attempt cardiovascular resuscitation (DNACPR) decisions.

We saw evidence of patients being involved in the management of their long-term conditions and were given opportunities to choose different ways to manage their health.

The staff and leaders had oversight as clearly defined by their roles. However, there were gaps in ensuring risk assessments were being carried out in a timely manner. Staff were aware that risk assessments had not been undertaken, and immediately after the inspection, both a fire risk assessment and health and safety risk assessment were carried out.

A defibrillator, medical oxygen and emergency medicines were stored in the practice nurse’s room and were within date. We found that all fire extinguishers were out of date and not serviced since 2022. We also found that two of the fire extinguishers were not appropriately fixed to the walls and were observed to be loosely hanging off their wall brackets. After the inspection, we were sent evidence that all fire extinguishers had been replaced or serviced, and the two wall brackets had been fixed.

There was a policy for health and safety. Fire safety training was completed by staff. There was a recent and appropriate risk assessment for legionella bacteria including action logs. Medical equipment calibration and Portable Appliance Testing (PAT) certificates were in place and a business continuity plan, all of which were up-to date. The business continuity plan detailed what actions were to be taken in the event of any incident that would hamper the running of the services. However, we noted that a health and safety risk assessment and fire risk assessment had not been carried out since 2022. This posed the risk of staff not being aware of, or mitigating any fire, health and safety hazards in and around the premises.

Staff told us that the staffing level was sufficient and staff holidays, sickness / absence were covered adequately. However, the leaders recognised there was a need for upskilling staff and increasing managerial staff. There was only one GP partner who was actively involved in the running of the practice, and they told us that the work can become difficult to manage and overwhelming at times. As a result, they had applied for a merger with a local practice, which is currently under review by the local healthcare authorities.

The staff records reviewed by the inspection team were up to date and included a formal induction process for new staff members and staff vaccination records. All staff trainings were within date with alerts / reminders sent to staff about soon to expire training. Staff had completed chaperone training. All relevant policies were reviewed regularly and within date. We saw the practice had a recruitment policy which was updated regularly. Recruitment checks were carried out. We sampled recruitment checks for both staff and GPs and saw that checks had been undertaken prior to employment. For example, proof of identification, references, qualifications, registration with the appropriate professional body, staff had a contract of employment.

Staff we spoke with had a good understanding of infection prevention and control (IPC). Staff were aware who the IPC lead was for the practice and IPC audits were completed six monthly.

We found the practice to be clean and hygienic. We found that all sharps bins were clearly labelled and disposed of in a timely manner. Soap dispensers and paper towels were available, as well are personal protective equipment. There was adequate cleaning schedules and logs in place. All relevant medicines and vaccines were stored in a locked fridge, at the correct temperatures, and were in date.

At our last inspection, we found there was lack of records regarding the immunisation status of staff. At this inspection, we found that details of the immunisation status of clinical and non-clinical staff were now appropriately recorded and kept up to date. The practice had an infection prevention and control (IPC) policy that was last reviewed in April 2024. We saw evidence there were annual IPC audits completed, with the latest completed March 2024. The most recent audit did not highlight any areas of concern. All staff were up to date with their IPC training.

As part of our assessment we interviewed the clinical lead GP. They were able to explain to us systems for the appropriate and safe use of medicines, including medicines optimisation the practice had. However, upon review we had concerns regarding the prescribing of some high-risk medicines and administration of vaccines by the healthcare assistant.

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. There was medical oxygen and a defibrillator on site and systems to ensure these were regularly checked and fit for use. Vaccines were appropriately stored, monitored and transported in line with UKHSA guidance to ensure they remained safe and effective. We were also satisfied that the practice had an appropriate system in place to monitor and action patient and medicines safety alerts.

We carried out remote searches of clinical records as part of our assessment to check how the practice monitored patients’ health in relation to the use of high-risk medicines. We reviewed numerous medicines and found that in most cases patients received appropriate monitoring at the required intervals. However, there were concerns regarding the prescribing of three medicines. Our clinical searches highlighted 10 patients were prescribed methotrexate which is an immunosuppressant medication. A sample of four of those patients showed they had not received the required monitoring. Clinical searches highlighted 18 patients prescribed a potassium sparing diuretic. A sample of three of those patients showed that had overdue monitoring. We reviewed four patients prescribed metformin, which is a medicine to treat type-2 diabetes. All four patient test results indicated they were under the threshold for a diabetes diagnosis, and therefore this medicine should have been reviewed and stopped. After the inspection, the practice audited all patients on the above three medicines and provided evidence that they had now carried out the correct interventions.

We saw that the practice ensured medicines were stored safely and securely with access restricted to authorised staff. Nursing staff had the appropriate authorisations to administer medicines, including Patient Group Directions. However, we found that the healthcare assistant (HCA) was administrating influenza vaccines and vitamin b12 injections, without patient specific directions. A Patient Specific Direction (PSD) is an instruction from a clinical prescriber for medicines to be supplied and/or administered to a named patient after the prescriber has assessed the patient on an individual basis. Patients were therefore at risk of being administered medicines incorrectly. Following the inspection the HCA re-trained in vaccine administration, and we were sent evidence of PSD’s which were reviewed and signed off by the GP. Following the inspection the HCA re-trained in vaccine administration, and we were sent evidence of PSD’s which were reviewed and signed off by the GP.

The practice did not have safe system for the storage and allocation of blank prescription pads. On the day of assessment, we noticed that blank prescription pads were kept unsecured on a shelf in the reception area. This was easily accessible as the reception door was kept unlocked. In addition, staff told us they would hand out prescription pads upon request and did not have a system in place to record and monitor the allocation of the prescriptions allocated to staff. This posed the risk of prescription pads being misused by staff and patients. After the inspection, we were provided with evidence that blank prescription pads were being stored securely and appropriately monitored.

The prescribing data reviewed as part of our assessment included antibiotics, and psychotropics which showed that the practice was performing in line with national averages to reduce the risk of antimicrobial resistance and the misuse of addictive medicines.