Feltwell Surgery

We carried out an announced comprehensive inspection at Feltwell Surgery on 23 January 2020 as part of our regulatory response to breaches of regulation identified at our previous inspection.

At the last inspection in June 2019 we rated the practice as requires improvement overall and inadequate for providing safe services because:

• The provider did not ensure the proper and safe management of medicines by assessing and mitigating risks to patients associated with changes to the prescribing system.

We served the provider with a warning notice for breaches of Regulation 12 of the Health and Social Care Act (Regulated Activities) Regulations 2014 Safe Care and Treatment.

At this inspection, we found that the provider had satisfactorily addressed these areas.

We based our judgement of the quality of care at this service on a combination of:

• what we found when we inspected
• information from our ongoing monitoring of data about services and
• information from the provider, patients, the public and other organisations.

We have rated this practice as Good overall because:

• The practice provided care in a way that kept patients safe and protected them from avoidable harm, including the safe management of medicines.
• Patients received effective care and treatment that met their needs.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
• The way the practice was led and managed promoted the delivery of high-quality, person-centre care. The practice had taken action to remove and reduce risks to patients identified at our last inspection.

Whilst we found no breaches of regulations, the provider should:

• Implement a standard operating procedure for the maintenance of the vaccine cold chain in line with best practice.
• Consider further best practice guidance that medicines in their original packaging should not be included in monitored dosage systems.
• Formally assess the safety, security, confidentiality and traceability of the medicines delivery service.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

We decided to undertake an inspection of this service following our annual review of the information available to us. This inspection looked at the following key questions; are services effective and are services well-led. During the inspection we identified issues prompting us to also ask are services safe.

We based our judgement of the quality of care at this service on a combination of:

• what we found when we inspected
• information from our ongoing monitoring of data about services and
• information from the provider, patients, the public and other organisations.

We have rated this practice as requires improvement overall.

We rated the practice as inadequate for providing safe services because the provider had not identified or mitigated the risks to patients associated with changes implemented in the prescribing system:

• The practice standard operating procedures did not require prescriptions to be authorised by a prescriber before medicines were dispensed to patients. Prescriptions were only authorised after patients had collected their medicines. For example, we saw 184 unsigned prescriptions for repeat medications, high risk medicines and controlled drugs that had already been collected by patients.
• The practice had systems and processes in place for clinical, non-clinical and dispensary staff to check that patients requesting high risk medicines or repeat prescriptions were up to date with their monitoring requirements. There was a process in place for dispensary staff to raise any concerns with clinicians by issuing tasks on the practice computer system. However, there was no process in place for ensuring these tasks were completed before patients collected their medicines.
• Prescriptions generated by nurses in the minor illness service were not always authorised by a prescriber. Nurses were appropriately trained for their role and a there was a process for ensuring competence before nurses were able to see patients in the minor illness service. There were appropriate safety systems to ensure Nurses had access to GP and peer support when necessary and where a patient was referred to a GP, a review of clinical practice was undertaken, and feedback provided. However, there was no formal process in place to regularly review clinical practice or prescribing through a formal clinical supervision or peer review process to ensure their compliance with practice prescribing policy or national clinical guidelines.
• The practice stock of emergency medicines included a controlled drug which was not securely stored in line with the Misuse of Drugs Act 1971 and subsequent regulations. The practice told us this would be removed immediately and stored securely.
• The practice recorded serial numbers for blank prescription stationery on delivery and stored them securely prior to distribution; however, there was no process in place for the recording of the distribution of blank prescription forms, their secure storage after distribution, or managing missing, returned or destroyed prescription stationery in line with guidelines.
• Dispensary staff told us that a full stock check had been completed in April 2019 but there was no evidence of this at the time of inspection. The dispensary had introduced sectional stock checks on a rolling programme which were recorded; however, this was not supported by a standard operating procedure.
• The dispensary issued medicines for some patients in monitored dosage systems (MDS); however, the practice had not assessed the risk to patients of providing medicines cut out but not separated from their foil packaging, in line with good practice.
• The dispensary had a system for reporting and reviewing incidents and near misses, however there was no formal system for reviewing and monitoring overall trends and taking action. The process in the dispensary was different to the system in the practice and it was not always clear what action had been taken.

We rated the practice as good for providing effective services because:

• Patients received effective care and treatment that met their needs.

We rated the practice as requires improvement for providing well-led services because:

• the processes for managing risks, issues and performance were not always clear and effective; the provider had not identified and mitigated the risks associated with changing their prescribing system.
• There was no formal process in place to demonstrate the prescribing competence of nurses, no regular review of their prescribing practice and no formal clinical supervision or peer review process to ensure their compliance with practice prescribing policy.

We rated all population groups as good.

We did not inspect the practices caring and responsive services at this inspection and have used the previous ratings of good in making our judgement:

The areas where the provider must make improvements are:

• Ensure that care and treatment is provided in a safe way.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

• Review and improve the system for the safe and secure management of blank prescription stationery.
• Review the dispensary near miss and incident reporting system and implement a formal system for reviewing and monitoring overall trends and taking action.
• Review the provision of medicines in foil packages in monitored dosage systems to identify and mitigate risks to patients.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care