Pontesbury & Worthen 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

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 has changed to Requires Improvement.

The service was in breach of legal regulation in relation to safe care and treatment.

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 provider had processes for staff to report incidents, near misses and safety events. Staff told us they felt supported to raise concerns and that there was an open culture. We saw evidence that some significant events had been recorded and discussed within a significant event meeting, that occurred every 6-8 weeks or sooner within a management meeting if urgent. However, the provider’s own procedures were not followed when reporting dispensing errors and near-misses.

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. We found that the website did not provide clear guidance on who to contact should people want to raise a complaint.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made 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. The service worked with other providers to deliver shared care and when patients moved between services. Referrals and test results were managed in a timely way.

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.

Safeguarding policies were in place and known to staff, who were trained in safeguarding procedures. The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations. Systems were in place to alert the safeguarding lead and to follow-up on patients who were frequent attenders to the Accident and Emergency department. This was also the case for patients who had failed to attend appointments in secondary care and/or primary care.

Overall, the service worked with people to understand and manage risks.

Emergency equipment was available, maintained and easily accessible in the Pontesbury site. Staff did not have immediate access to resuscitation equipment or medicines at the Worthen branch as these were kept in a treatment room accessible by a coded lock. Staff told us they would consider relocating these to a more suitable area. All of the suggested medicines and equipment was available except for a supraglottic airway device. Checks were carried out weekly and recorded on the practice’s workforce management platform. (GP TeamNet). Expiry dates of medicines held were recorded. Staff were unaware if a local risk assessment had been undertaken, for example the availability of other services, expected ambulance response times and proximity of nearest hospital.

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

The service detected and controlled most potential risks in the care environment. Records sampled showed all the required health and safety checks had been undertaken with the exception of fire evacuation drills at the Worthen branch. No mains electrical fire alarm system was fitted in the branch surgery, only smoke detectors were present and tested weekly.

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 except for the fire alarm at the branch surgery. There was a business continuity plan in place which was monitored and reviewed.

The practice employed a team of 39 staff with a range of clinical and non-clinical roles who worked across both sites. We found training was mainly up to date, learning needs and development of staff was managed, and staff were working within their agreed areas of competence. Staff told us they were provided with good training opportunities, and their learning and development needs were identified and discussed with them.

A number of new staff had been employed in the previous 12 months. We sampled 5 staff files and found information was well presented however, the practice was not working in line with their recruitment policy. We found a significant number of shortfalls in safe recruitment practices as the required checks had not been obtained prior to new staff commencing work. These included disclosure and barring (DBS) checks, references and satisfactory information regarding physical and mental health conditions. Gaps in employment history had not been explored. Staff induction records were available; however, these were not specific for their role or signed and dated.

Assurances had been obtained from the Primary Care Network (PCN) confirming that the required recruitment checks for all staff working at the practice employed under the Additional Roles Reimbursement Scheme (ARRS) had been undertaken and staff had completed all required training.

Following the inspection the practice told us that they would undertake a risk assessment of current employees where gaps had identified within their records. They also planned to introduce an occupational health questionnaire to be completed, which would also include their immunisation status.

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 (IPC) and all staff had received relevant training. The practice used an external cleaning company, who produced their own infection control audits. Cleaning schedules were in place and followed. Staff had access to personal protective equipment (PPE) and arrangements were in place for the disposal of clinical waste. Risk assessments and audits were completed, and actions taken to mitigate risks. The areas we saw during an environmental tour of both sites were visibly clean and hygienic. In response to a concern raised about infection control practices, the practice had reviewed its protocols. The IPC lead had set up learning group sessions for all staff to support them in this area.

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. Our remote clinical searches found 508 patients had received a medication review in the previous 3 months and all were found to be satisfactory. We found that staff followed established processes to ensure people prescribed medicines with specific risks received the recommended monitoring. Medicines at the practice were stored securely, and medical gases such as oxygen were stored safely.

The service managed prescription stationery securely, and in line with national NHS guidance. Paper prescriptions were tracked safely within the service.

We inspected the dispensary at Pontesbury and found that prescriptions were not always signed by a prescriber on the day they were issued. Numerous examples were seen of prescriptions awaiting collection from patients that had still not been signed by the GP. This was not in accordance with national guidance. As a result, medicines were being dispensed without appropriate authorisation, potentially compromising patient safety. We highlighted this during inspection, and the provider assured us that they would review procedures to prevent this from happening again.

For dispensing errors, a near-miss recording sheet was available; however, staff were not using it, and some did not know it was present in the dispensary. Staff were going directly to the practice manager with near misses; however, this did not follow the provider's own procedures.

Controlled drugs (CDs), medicines requiring additional security measures due to the potential for misuse and diversion, were stored securely. CD balance checks were not being completed at the frequency set out in the provider’s policies. An incorrect balance for a medicine was identified in the CD register at Pontesbury, and this discrepancy had not been detected during previous balance checks. A CD register had been archived of a medicine that was out of date and still being held in the safe. These findings indicated that the provider could not be assured that CD discrepancies were addressed in a timely manner, increasing the risk that errors or misuse would go unnoticed.

A CD in a bag awaiting collection by a patient was found to contain an incorrect quantity of medicine. There was no owing balance of the outstanding quantity of medicine on the prescription. This may have resulted in a dispensing error.

Stock checked in the dispensary was in date. However, there was no date-checking schedule in place at the dispensary, and staff were unaware of a standard operating procedure for date checking.

At the Worthen branch, we found a CD register was present, but no entries had been recorded since 2019. We were told CDs were signed in on a log sheet and when patients collected these, their identity was checked.

Staff had the appropriate authorisations in place to administer medicines under Patient Group Directions (PGDs). Two PGDs were signed by the GP before the staff, which meant that the staff had not been correctly authorised to supply or administer medicines. After we highlighted this, it was corrected on the day of the inspection.

Emergency medicines were in place to manage patients presenting with an emergency condition, and they were checked regularly. However, several items of clinical equipment were found to have expired. The lead GP advised that they had chosen not to dispose of these items as they were non-sterile plastic. During the inspection, after prompting, the GP completed a risk assessment for the use of out-of-date clinical equipment.

Repeat prescription requests were observed being processed by staff; however, medicines were still being issued after their review dates had passed, and there was no process in place to ensure these patients were reviewed by clinical staff. When this was discussed with the lead GP, we were advised that a new system was being developed to address this.