The Northenden Group 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.

The service did not always demonstrate an effective learning culture, although people were consistently supported to raise concerns. Even though managers did investigate incidents thoroughly, systems to ensure people were protected and kept safe were not reliably implemented. Staff did not consistently understand or manage risks. Although facilities and equipment were generally clean and well maintained, risks were not always identified or mitigated in a timely manner. There were enough staff with the right skills, qualifications and experience. Managers did not ensure all staff received required training or regular appraisals to maintain high quality care. Staff did not always manage medicines safely or involve people effectively in planning any changes.

At our last assessment, we rated this key question as good. At this assessment, the rating has changed.

The service was in breach of legal regulation in relation to safe care and treatment, good governance, and staffing.

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.

The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. Representatives from the PPG felt the provider took concerns seriously and proactively made improvements to the service. Managers encouraged staff to raise concerns when things went wrong. During staff meetings, the whole team discussed and learnt from clinical issues. Staff felt there was an open culture, and that safety was a priority. The provider 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. Learning from incidents and complaints resulted in changes that improved care for others.

The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make 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. However, when patients moved from other services, we found that information was not always correctly recorded, especially information relating to allergies. This meant that allergy alerts would not always be triggered when prescribing medications.

We also found there was a lack of safe systems for managing long term conditions, resulting in patients that had gone without effective and safe monitoring of their conditions.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. 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 service shared concerns quickly and appropriately.

The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations. However, at the time of our clinical searches, we found there were no alerts on some patients, and incorrect coding on patients with prior safeguarding issues.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. However, the service did not monitor staff safeguarding training effectively, resulting in overdue mandatory training for staff.

The service did not always work well with people to understand and manage risks. They did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff could recognise a deteriorating patient and knew of action to take. Patients were advised on risks related to their condition and on the actions to take if their condition deteriorated.

While emergency equipment was available, we found that the emergency medicines were stored between an emergency trolley, a nurse’s cupboard, and a home visit bag. We also found that several emergency medicines had expired, and the provider did not have a safety risk assessment arrangement at the time of our inspection.

The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Contracts were in place to ensure the premises were maintained. Health and safety risk assessments and audits had been undertaken and risks identified had been addressed. There was a business continuity plan in place which was monitored and reviewed.
 

The service did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.
Learning needs and development of staff was managed appropriately. However, we found many staff, both clinical and non-clinical, were not up to date with mandatory training, including basic life support.

Training for all staff is important to help ensure a high quality of care and safety for patients. To deliver safe, high-quality care and treatment, reasonable steps to support staff to do their jobs must be taken. This is to keep both patients and practice staff safe.
 

The service 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 a designated infection, prevention and control lead and all staff had had relevant training. Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.
Medicines including controlled drugs were stored securely and at appropriate temperatures. Fridge temperatures were recorded, but when temperatures went outside the safe range there was no clear record of what action had been taken. Without proper monitoring, medicines may not stay safe or effective.

Waste medicines were recorded and disposed of appropriately including medicines returned by patients. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments.

We spoke with the practice pharmacist to understand their role, responsibilities and the systems in place to support safe medicines management. They worked full time as a non-medical prescriber, prescribing only within their agreed area of competence while carrying out structured medication reviews, managing prescribing queries and supporting long term condition management. The pharmacist described clear processes for reviewing clinical documents, updating prescriptions, running medicines safety searches and involving patients in decisions about their treatment.

We found that several people taking medicines used for blood pressure and heart/kidney conditions were not receiving their regular blood tests and blood pressure checks. People had gone 22 months and, in some cases, almost 3 years without essential monitoring. This meant conditions like kidney disease, high blood pressure, or medicine-related problems could go unnoticed, putting people at risk of avoidable harm.

We found that patients were being prescribed more reliever inhalers than is considered safe. Reliever inhalers should only be needed occasionally, as frequent use is a sign of poorly controlled asthma. Some patients had missed routine asthma reviews, or it was documented they were not using their preventer inhalers correctly. These issues increased the risk of their asthma becoming severe or potentially life-threatening.

Patients with serious allergies did not have their allergies correctly recorded on their medical records. Some patients had adrenaline autoinjectors for severe allergies that had been issued a long time ago, and it was unclear whether these were still in date. Others had no injector available despite a history of severe allergic reactions. Missing allergy codes meant the system could not alert staff to life-threatening allergies, increasing the risk of unsafe prescribing.

Although some patients had recently had medication reviews coded on their records, the reviews had not always been fully completed. Some people were missing important blood tests and some had incorrect medicines left on their repeat list. This created risks such as taking incorrect doses, not recognising worsening health conditions, or missing opportunities to adjust medicines safely.

We found prescription pads were not being tracked properly. Some logs were incomplete, one prescription form could not be accounted for, and serial numbers had been recorded incorrectly. This meant there was a risk prescription forms could be lost or misused.

Following the inspection the provider took steps to improve the systems and processes they had in place in relation to medicines management and were providing CQC with updates and an action plan to evidence action taken and how these would be sustained.