Pembroke House Surgery

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 assessed all quality statements in the safe key question.

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 remains the same.

The service regularly reviewed, analysed and learnt from events and incidents. The service had clear systems and processes to keep people safe and safeguarded from abuse. The facilities and equipment met the needs of people and were visually clean and well-maintained. However, the recruitment processes and staff training were not in line with the service’s policies and the service’s management of medicines was not following best practice guidance. The service was responsive in taking actions to immediately rectify the issues.

This service scored 72 (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. Staff understood how to raise concerns and report incidents. Staff told us there was an open culture, and safety was a top priority. The service had processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints and incidents. When things went wrong, staff apologised and gave people support. The service held monthly designated significant event analysis meetings and complaints were discussed in weekly management meetings. Learning from both meetings were shared to improve people’s care. Meeting notes were shared with all staff, including those who could not attend. We saw evidence the service managed complaints and incidents in line with their policies and learnt from them.

The service worked with people and healthcare partners to maintain safe systems of care. They made sure there was continuity of care, including when people moved between different services.

There were systems for processing information relating to new patients. Staff had clear responsibilities and followed systems to ensure continuity between secondary and primary care. Referrals and clinical correspondence, including test results, were managed in a timely manner, which included a system for covering arrangements during staff absences. Designated administrative staff were responsible for managing and monitoring referrals to ensure people were referred to other services appropriately and were prioritised for urgent actions.

The service 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 with relevant partners.

The service’s child and adult safeguarding leads worked collaboratively to maintain accurate lists of vulnerable children and adults with regular updates and acted on concerns, working in partnership with other organisations. The service regularly discussed safeguarding concerns in monthly multi-disciplinary team meetings which were attended by external partners including midwives, social prescribers and local experts in domestic abuse and sexual violence. The safeguarding leads engaged with the local integrated care board (ICB) for advice and attended their safeguarding training and meetings.

The service had clear systems and processes to keep people safe and safeguarded from abuse. Alerts on clinical records flagged people with safeguarding concerns, including their household members. The service had safeguarding policies for children and adults which were accessible to all staff. The policies contained detailed internal safeguarding processes, safeguarding training requirements and contact details of local safeguarding teams. Staff could explain the safeguarding processes and felt confident in raising concerns. Staff knew who the safeguarding leads were. However, 13% of staff (including both clinical and non-clinical) were not up to date with their safeguarding children and vulnerable adults training at the appropriate level for their roles. The service immediately developed a detailed process to monitor and maintain oversight of the completion of mandatory safeguarding training within the next 3 weeks.

The service worked with people to understand and manage risks. They provided care to meet people’s needs that was safe and supportive.

Emergency equipment was available and maintained with regular checks at both sites. Leaders had risk assessed which emergency medicines it required in the service and ensured these medicines were appropriately stocked and checked regularly.

Staff could recognise a deteriorating patient and knew of action to take. Staff could summon help quickly in an emergency using the emergency button on the computer system or via a panic alarm in consulting rooms. The duty GP was readily available to provide support to the receptionists. The service had a medical emergency policy covering actions to take, staff roles and responsibilities. People received advice on risks related to their condition and the actions to take if their condition deteriorated.

However, 4% of staff (all clinical staff except one) were not up to date with their adult and paediatric basic life support training. Following our onsite visit, the service developed a detailed process to monitor and maintain oversight of the completion of mandatory training within the next 3 weeks.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The service was well-maintained and free from clutter at both sites. The facilities and premises were appropriate for the services being delivered. Lead roles for health and safety were clearly defined. Health and safety risk assessments were carried out and appropriate actions were taken where needed. Fire equipment checks were documented. Electrical equipment was tested to ensure it was safe to use and equipment was calibrated for accuracy. The service had a health and safety policy and business continuity plan detailing what actions were to be taken in the event of any incident which would affect the running of the services. There was a lone working policy and risk assessment to promote staff safety at both sites.

The service did not always make sure there were enough qualified, skilled and experienced staff based on the gaps in the recruitment process and training monitoring. The service made sure staff received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Safe recruitment practices were not consistently followed. For example, during a review of recruitment records, 4 out of 5 records did not contain 2 references from a previous employer and 2 non-clinical staff records did not contain the required risk assessment instead of a Disclosure and Barring Service (DBS) check, as required by the service’s own recruitment policy. Following the onsite visit, the service immediately conducted a DBS risk assessment for those non-clinical staff members, detailing the rationale for the decision. The service also developed an action plan to reinforce the process of obtaining references during recruitment.

The service’s completion of mandatory training for staff ranged between 77-97%. The service immediately developed an action plan to maintain oversight of training compliance and ensure there is protected time for mandatory training.

However, there was a range of clinical and non-clinical roles within the service. Most staff expressed that there were enough staff to provide safe and high-quality care. Nevertheless, the service was recruiting more GPs to cope with the increasing demand for routine appointments. Staff received induction appropriate for their roles and staff were working within their agreed areas of competence. There were policies and processes for clinical supervision and staff had regular appraisals. Staff were able to discuss their learning needs. Poor performance was recognised and managed which was evidenced by an example. We saw evidence of staff being upskilled to support the service and their professional development. For example, the service supported their staff by giving protected time and funding to pursue training in advanced clinical practitioner and speciality nurse roles.

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 service had a designated infection prevention and control (IPC) lead, and all staff were aware of who the person was. The IPC policy was accessible to all staff. Staff knew how to manage clinical waste and specimens. We observed the service was visibly clean and tidy during the onsite visit. Up to date IPC risk assessments and audits were completed, and actions taken to mitigate risks. Cleaning schedules were followed and the service met with the external cleaning company regularly to discuss any identified issues. Personal protective equipment (PPE) was available to staff and there were hand-washing facilities in all clinical areas. Sharps waste bins were safely managed. During the onsite visit, all except one of the clinical waste bins were locked and stored securely. A clinical waste bin at the branch site was not locked. However, there was general waste and not clinical waste inside. The service explained that the bin was out of contract and awaiting removal. Following the onsite visit, the service locked the clinical waste bin to prevent unauthorised use before removal by the contractor. On review of the service’s staff training records, there were 3% of non-clinical staff and 5% of clinical staff who were not up to date with their IPC training. The service immediately developed an action plan to catch up with all mandatory training within the next 3 weeks.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

The service had policies and procedures for the management of medicines. Vaccines were appropriately stored and monitored in line with national guidance to ensure they remained safe and effective. The service had a process for authorising staff to administer medicines including Patient Group Directions (PGDs) or Patient Specific Directions (PSDs). PGDs are a written instruction for the supply and/or administration of a named licensed medicine for a defined clinical condition. PSDs are a written instruction from a doctor or other independent prescriber for a medicine to be supplied or administered to a named patient. Blank prescription stationery was securely stored in a locked cupboard in line with national guidance. Annual auditing of non-medical prescribers (NMP, healthcare professionals who can prescribe medicines but are not GPs) was started last year. This was to ensure medicines prescribed were necessary, correctly prescribed and followed up when needed. The audit for this year was overdue but was in progress during our onsite visit. The service developed an action plan to complete the NMP audit within 3 weeks. The service also developed a new tracker system to monitor audit completion more closely.

As part of our inspection, a number of set clinical record searches were undertaken remotely by a CQC GP specialist advisor. These searches were visible to the service. Our clinical searches on people coded as having a medication review in the last 3 months showed that all 5 records we sampled received appropriate medication reviews with no issues with monitoring or evidence of potential harm. The clinical searches showed that 6 out of 116 people on methotrexate (a medicine used to treat inflammatory conditions and some cancers but can have serious side effects on blood cells, liver and kidney) were potentially not having the required monitoring in the last 6 months. We sampled 5 clinical records and found 3 of them were under monitoring by the hospital and 2 were already contacted by the service before the searches but the people did not respond to the service. The service audited all people in this group for any overdue monitoring and follow-up as appropriate. Clinical search showed 25 out of 47 people on amiodarone (a medicine for treating heart rhythm problems but with risk of serious side effects on lungs, liver and eyes) were potentially without required monitoring. We sampled 5 clinical records for review, and found 4 of them were under monitoring by hospital care management and a blood test appointment had already been booked for the remaining one before the searches. The service audited all people in this group for any overdue monitoring and follow-up as appropriate. The service also developed action plans to strengthen the processes of relevant monthly searches and monitoring. However, our clinical searches showed 108 people were prescribed bisphosphonate (a medicine to treat or prevent osteoporosis) for at least 5 years. We sampled 5 records for review and 4 of them had not been reviewed in line with national guidelines. The service developed an action plan following our inspection to review this group of people within a month. The service also developed new processes to regularly monitor this specific group of people. Our clinical searches then identified 74 people on a combination of clopidogrel (a medicine that prevents blood clots and reduces the risk of heart attacks and stroke) and omeprazole or esomeprazole (medicines that make clopidogrel works less well), which was not in line with nationally issued safety alert. The service developed an audit plan and would review the group of people within 2 months.

Prescribing data showed the prescription of an antimicrobial to treat urinary tract infection was higher than the national average. The service was aware of the finding and taken actions to address this. For example, the service addressed historical prescribing of antimicrobials with clinicians and reminded clinicians of cautious antimicrobial prescribing at clinical meetings. The rest of the service’s prescribing data for other antimicrobials, hypnotics (medicines that promote sleep) and gabapentinoids (medicines prescribed for treatment of epilepsy, neuropathic pain or generalised anxiety disorder but with risk of misuse or dependence) were in line with national averages.