Gosberton Medical 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 a total of 3 quality statements from this key question. We have combined the scores for this question with those from our previous inspection. Our rating for this key question was good. Significant events and complaints were appropriately managed however learning from these was not always shared with all staff. Staff were appropriately trained, recruited and competencies were maintained to ensure they were up to date to deliver a variety of services to patients. Systems and processes were not consistently in place to ensure patient’s medicines were well managed and reviews for long term conditions were variable. The dispensary was well managed and medicines securely stored.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Representatives from the Patient Participation Group (PPG) felt the provider was receptive to issues they raised and that the practice valued the PPG’s input.

When we spoke with staff, they told us that learning from complaints and significant events was not always shared efficiently across the whole practice team. The leadership team told us they communicated via email and had held meetings but not with all the staff present. They acknowledged that overarching staff meetings including all staff did not take place.

Staff felt able to raise concerns and felt that their concerns would be listened to. Staff were aware of how to report incidents, but some staff were not clear what constituted a significant event.

A new lead had been identified for significant events and complaints in October 2024. The practice had systems and processes in place to record and manage any events and complaints in a timely way, these systems were being streamlined at the time of our inspection. Policies were in place for Handling Serious Untoward Incident (HSUI), Complaints and Significant/Critical Event Toolkit (SCET) these included a reporting process for staff to raise concerns. An annual review of complaints was undertaken for ongoing external reporting requirements, this was not shared with staff. An inhouse annual review of significant events to allow a trend analysis over time to identify themes and share with staff was not undertaken.

The policies had been reviewed in the previous 12 months, the HSUI included details of an out-of-date NHS Reporting system that had not been used since 2022 and the SCET included details of a member of staff who had left the practice as a responsible individual. This meant staff did not always have easy access to appropriate information.

There was a culture of learning with staff encouraged to report concerns. The practice demonstrated how they investigated, identified learning, and made any improvements that were required. We reviewed some ways the practice shared learning with staff such as different staff groups team meetings where significant events and complaints were discussed. Meeting minutes were taken which demonstrated a formal approach to managing learning. Not all staff groups were involved in these meetings.

The dispensary manager recorded dispensary incidents and near misses and these were reviewed regularly to identify themes, communicated to staff and acted upon to reduce the risk of any reoccurrence.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

The PPG felt the practice was well staffed with an appropriate skill mix.

Overall, care homes felt clinical input from the practice was positive. They were in the process of adapting to changes relating to joint working with the Primary Care Network to provide care for their residents.

We received feedback from staff through interviews and staff questionnaires. The majority of staff felt the practice was appropriately staffed. If there were gaps in the rota, staff felt this was well managed.

Staff held appropriate qualifications and were fairly recruited to their roles. Staff felt supported by senior staff in seeking advice on a daily basis where needed. Formal supervision was taking place from September 2024. Staff reported being happy in their roles and felt the practice worked as a team.

Examples were seen of how conflict was resolved and this was appropriate. The majority of staff felt they received detailed appraisals. One appraisal was overdue but we saw evidence this was completed following our assessment.

Recruitment checks were carried out and evidenced in staff files, including for locum staff. Staff were appropriately inducted into their roles and were regularly reviewed by the management team.

Key areas of learning were found to be up to date on the whole and how this was recorded allowed employees the opportunity to review their own records to ensure training was current. Staff were encouraged to seek additional skills and were supported by the practice in doing so. Evidence of valid competencies were seen.

There was a satisfactory skill mix at the practice.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

Two of the care homes told us that they used the dispensary on site for prescriptions and had experienced issues with incorrect medicines received. They told us they had experienced variable communication with the dispensary regarding such issues.

Leaders told us there were systems and processes in place to manage MHRA alerts and the safe prescribing of medicines. However, the remote clinical searches we carried out showed that medicines were not always suitably managed and patients were not always informed of associated risks. Following our assessment leaders told us they had taken action to address the concerns identified.

We saw a range of emergency medicines in place in two locations and within a GP emergency medicine bag. Risk assessments were not available to support decisions not to stock emergency medicines in line with national guidance or where specific emergency medicines were located. A process was not in place to monitor usage of the emergency medicine doctors bag.

Vaccines were appropriately stored. The fridges were used only to store vaccines, on the day of our inspection they were highly stocked as a new fridge was ordered following a breakdown. Recording of the fridge temperatures were consistent with 24-hour temperature monitoring device in use.

The dispensary was clean, tidy and well organised with only authorised people having access.

Medicines stocks within the dispensary were secure, managed well, and expiry dates regularly checked.

Standard Operating procedures were in place for all the dispensary activities.

Remote clinical searches carried out found that certain high-risk medicines were not appropriately managed, and some patients were placed at potential risk.

Medicines reviews had taken place but were not structured and reviews of diabetes did not always include all required elements.

A process was in place to ensure emergency equipment and medicines were regularly checked and fit for use.

We found that the process for monitoring the temperature of the vaccination refrigerator was not fully effective. The temperature monitoring log was not comprehensive and did not include all the information needed to assure the provider of safe storage of medicines. The provider updated the temperature monitoring log during our inspection.

Patient Group Directions (PGDs) were in place to allow nurses to give vaccinations without a prescription and these had been appropriately authorised for use within the service.

Dispensary staff recorded incidents and near misses and these were reviewed regularly to minimise any reoccurrence.

Prescription stationery was managed appropriately.

There were appropriate systems and controls in place for the management of Controlled Drugs.

Searches carried out on the practice’s clinical systems found that the systems and processes in place to manage medicines and MHRA alerts were not wholly effective. Some patients were found to be overdue appropriate monitoring and were not reviewed in relation to these medicines. These patients were placed at risk as a result. The practice told us they had taken action to follow up and manage patients appropriately. They also told us they planned to review their system for recording and acting on alerts to ensure all alerts and relevant actions were clearly recorded.

The practice belonged to the Dispensary Services Quality Scheme (DSQS) and completed annual audits as part of this, changes were made following audits to improve patient outcomes. We found that outcomes for patients were not always optimised as the clinical searches we carried out identified that some patients were put at risk as they had not been appropriately monitored in respect of the medicines they were prescribed.It was not documented in some patients' clinical records that they had been advised of the risks associated with the medicines they were prescribed in line with national guidance This included aldosterone antagonists, methotrexate, the prescription of topiramate without a highly effective contraceptive, the co-prescription of simvastatin and amlodipine, the co-prescription of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers and patients over 65 on a non-steroidal anti-inflammatory drug or patients over 75 on an antiplatelet with no proton pump inhibitor prescribed. Remote clinical searches also looked at patients who had received a medicines review in the last 3 months. We found that in some cases, a medicines review had been coded as having been completed but there was not evidence that all medicines prescribed had been reviewed appropriately. The clinical searches carried out also looked at patients who had asthma and had been prescribed 2 or more courses of rescue steroids for an acute exacerbation of asthma. We found that patients were not always reviewed following this. We also looked at patients who had diabetes whose latest HbA1C result was greater than or equal to 75mmol/L. We found that some patients had not been reviewed following the result and some patients who had diabetes had not received an annual diabetic review. We also found that some patients who had hypothyroidism had not received a thyroid function test within the last 18 months.