Queenstown Road 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 Regulation 17 (Good governance) in relation to involving people to manage risks, safe and effective staffing, and medicines optimisation. This was because emergency medicines were not always routinely monitored, some emergency medicines stock was not available, there were gaps in staff training and recruitment files, and not all prescribed medicines were being monitored in line with national guidelines.

This service scored 59 (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.

Patients felt supported to raise concerns and felt staff treated them with compassion and understanding. 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 top 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 significant events resulted in changes that improved care for others. However, it was not clear that learning needs were identified as a result following complaints. The practice detailed what action had been taken, but it was not always clear how they mitigated the risk of reoccurrence.

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 patients 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.

Not all staff had completed the applicable safeguarding training applicable to their roles.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. The practice maintained a list of vulnerable patients and acted on concerns working in partnership with other organisations. The service shared concerns quickly and appropriately. The practice leads within the Primary Care Network (PCN) had set up an adults safeguarding group which held quarterly meetings to discuss particular cases and share learning.

Emergency equipment was not always available and maintained. There were no paediatric defibrillator pads available, nor were there intramuscular analgesics, antiemetics, antiepileptics, steroids or antihistamines. The practice advised that they had ordered antiemetics, antiepileptics and intramuscular analgesia prior to the site visit, and sent evidence to prove this was now in situ following the site visit. The practice stated that access to the other missing items could be easily obtained from nearby pharmacies; however, no accompanying risk assessment was in place at the time of assessment, including the time taken to access medicines in this way. The schedule for checking the emergency medicines stock was sporadic. For example, sometimes there were up to six months between the dates in which the emergency medicines stock was checked. We identified two out of date paediatric nebuliser masks during our site visit, which were immediately removed by the practice.

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 potential risks in the care environment. 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.

Whilst the service made sure there were enough qualified, skilled and experienced staff, they did not always check the immunisation status of non-clinical staff members. We reviewed two non-clinical staff member personnel files, and did not find evidence of immunisation status in either of their files. Following the site visit, we were provided with the immunisation status of one of these staff members, and a completed risk assessment which had been undertaken for the other staff member.

There were a range of clinical and non-clinical roles within the practice. We found training was mostly up to date. However, the two non-clinical staff personnel files we reviewed had not completed basic life support training since 2023. The non-clinical staff personnel files we reviewed had not completed learning disability and autism awareness training. One of these staff members was missing health and safety training and sepsis awareness training. Of the two clinical staff member personnel files we reviewed, neither had completed sepsis awareness training. One of these staff members had also not completed Mental Capacity Act training and learning disability and autism awareness training. Following the site visit, we were provided with evidence that all members of staff we reviewed (clinical and non-clinical) had since completed the required training.

Clinical staff did not always complete safeguarding training at a level applicable to their role. We reviewed two clinical staff members’ personnel files. One clinical staff member had not completed the required safeguarding training at a level applicable to their role. Following the site visit, we were sent evidence the clinical member of staff we identified had since completed the required level of safeguarding training applicable to their role. The staff training matrix also showed that clinical staff were not always allocated the correct level of safeguarding training applicable to their role.

It was not clear during our review of staff training files or the staff training matrix who was given chaperone training at the practice. The practice manager reported that all reception staff were chaperone trained. However, we only saw evidence of chaperone training in one of the non-clinical staff personnel files we reviewed during this assessment. The practice had sent a copy of an email from April 2023 confirming online chaperoning training, which all reception staff bar one had attended. However, no certification was available to support the completion of this.

The practice made sure staff received effective support, supervision and development. They worked together well to provide safe care that met patients’ individual needs.

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 made sure that medicines and treatments were safe and met patients’ needs, capacities and preferences. They involved patients in planning, including when changes happened.

We reviewed clinical records for patients who had been prescribed medicines which required routine monitoring. We identified 477 patients who were prescribed an angiotensin converting enzyme (ACE) or angiotensin receptor blocker (ARB) medicine, of which 8 patients had not received the required monitoring. ACE and ARB medicines are used to treat patients experiencing high blood pressure or heart failure. We reviewed 5 patient records and found that evidence that all of these patients had been invited by the practice to have their monitoring completed. Patients taking ACE and ARB medicines are at increased risk of developing hyperkalaemia (increased potassium in the blood) or acute kidney injury.

During our remote clinical records searches, we identified 2 out of 28 patients who were prescribed mirabegnon and had not received the required blood pressure monitoring. Mirabegnon is a medicine prescribed to treat patients with an overactive bladder. We saw evidence for both patients that the practice had contacted them earlier in the month to invite them for monitoring.

We identified 12 patients with a potential missed diagnosis of diabetes. We reviewed 5 of these patient records. Two of these patients were incorrectly coded as having prediabetes rather than diabetes. If a patient is not coded correctly on the electronic clinical records system, the patient will not be on the right care pathway for their condition and may miss important recalls for monitoring.

We identified 23 out of 98 elderly patients who were prescribed a non-steroidal anti-inflammatory (NSAID) or antiplatelet (blood thinning) medicine without a proton-pump inhibitor (PPI) medicine. A PPI medicine should be used alongside NSAID and antiplatelet medicines to prevent the likelihood of gastric bleeding in this patient group. We reviewed 5 of these patient records and found all patients required a PPI, but that this had not been prescribed.

The practice told us that they would address these omissions and review all identified patients following the assessment.

Staff involved patients in reviews of their medicines and helped them understand how to manage their medicines safely. Patients knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms. Staff received regular training, were competency assessed on medicines optimisation, and felt confident managing the storage, administration and recording of medicines. Staff managed prescription stationery appropriately and securely. Medicines were stored securely and at appropriate temperatures.