Parson Drove 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

This means we looked for evidence there was a culture of openness in which there was a willingness to identify and learn from safety events. We looked for evidence people were protected from abuse and avoidable harm.

At our last inspection we rated this key question Inadequate. At this inspection, the rating has changed to Requires Improvement. This is because although systems and processes had been put in place, the practice did not always consistently follow these appropriately.

We assessed a total of 8 quality statements from this key question. We undertook clinical searches on the practice clinical systems that showed significant improvements in medicines optimisation, in particular in the monitoring of patients on high-risk medicines. There were also significant improvements in the managing and oversight of test results. The service worked to safeguard people from the risk of abuse and demonstrated a joined-up approach to safety that involved the person themselves, staff and other partners in their care.

Whilst leaders promoted a proactive and positive culture of safety based on openness and honesty, evidence we reviewed did not demonstrate that this was always embedded. Learning from significant events had not always prevented them from reoccurring. Recruitment checks were also not always carried out in accordance with regulations. Whilst the provider was committed to improving the way they involved people to manage risks this required further improvement.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

As part of our inspection, we reviewed patient experience feedback sent to CQC, online feedback, complaints and significant event records. In addition, we also reviewed feedback provided through the Patient Participation Group (PPG).

People had opportunities to provide feedback to the practice and were aware of how to make a complaint. We noted that a high volume of complaints had been submitted to the provider in the last year. These complaints had not always been fully investigated and patients informed of the outcomes.

The practice had an active PPG. Representatives that we spoke to were positive about leaders working with them to improve services. The PPG felt the provider took people's concerns seriously and were proactively assisting with improvements to the service.

Some people we spoke with felt staff treated them with compassion and understanding. Others stated that they did not always feel supported to raise concerns and reported that some staff had been rude to them.

Most staff told us that they had received enough specific training for their role. However, there was not always formal training and sometimes only informal advice. Staff told us that the practice shared incidents, complaints, significant events and learning with them, but we found this was inconsistent.

The provider had implemented new systems for monitoring significant events and complaints since our previous assessment. The practice had moved to recording significant events and complaints on a nationally recognised system following the appointment of a new practice manager. This allowed the practice to track and audit complaints more easily. However, there was a variance in the quality of learning from significant events.

There was evidence that some learning from incidents and complaints had resulted in changes, however there were 3 occasions that a significant event had been repeated with the same learning outcomes. This indicated that the learning and actions had not mitigated the risk of the significant event from reoccurring.

Staff understood their duty to raise concerns, report incidents and near misses.

People we spoke with gave mixed feedback in relation to referrals being made appropriately and being supported during waiting times to be seen by other services. We received feedback from some members of the public who described waiting several hours for a call back, chased referrals and had experienced delays in care and treatment. Other people reported positive experiences with no concerns about referrals, pathways or transitions.

Some staff told us that there had been new arrangements put in place to improve tracking referrals, including electronic referrals and the oversight of urgent referrals relating to potential cancer diagnosis. Staff who undertook referrals to secondary care mostly understood systems and processes in place to minimise any potential delays.

There was a system for recording and acting on patient safety alerts. Our clinical searches of the practice system did not raise any concerns for this. Our review of patients’ records and the clinical system indicated that letters, referrals and blood tests results were being managed and responded to safely. The provider could mostly demonstrate that communication with other services was reviewed and acted on appropriately.

We received positive feedback from partners in Cambridgeshire Integrated Care Board (ICB) in relation to the improvements that have been made, including when patients were receiving care and treatment from a range of services. Despite the improvements, there were still some further actions required regarding the sustainability of the changes that had been carried out.

The provider had created new policies relating to care navigation, summarising, scanning and managing referrals. There were prompts outlined for non-clinical reception staff to help manage communication. Resources were available for staff regarding local referral processes and arrangements. However, these had not been embedded into routine practice.

The practice had recently introduced regular multidisciplinary team (MDT) meetings to keep oversight when patients receive care and treatment from a range of services.

There had been 3 significant events relating to delayed referrals, the actions identified had not mitigated the risk of the significant event from happening again. Therefore, although we found that the provider had made improvements since our last assessment, systems, pathways and transitions did not always work effectively. Leaders told us that they were committed to continuing to make improvements.

We did not receive any concerns from patients specifically about safeguarding. Therefore, we did not receive enough evidence from patients to score this evidence category.

Staff described their individual roles in ensuring patients, including vulnerable people, were followed up if they failed to attend appointments. Staff clearly identified two lead roles for safeguarding: a lead for adults and a lead for children. However, leaders told us that there was only one nominated safeguarding lead for both adults and children. Therefore, this was unclear and could result in confusion.

Since our previous inspection the practice had produced and maintained a list of vulnerable people. This list was reviewed regularly during monthly MDT meetings. The meetings were also attended by district nurses and palliative care staff.

The provider was working closely with the Cambridgeshire ICB to monitor outcomes relating to safeguarding. Despite the improvements made since our previous assessment, there were still further identifiable actions required regarding the sustainability of the changes.

The practice had implemented a new safeguarding policy. Staff had completed appropriate safeguarding training. On site we observed that there were posters in the clinical rooms offering a chaperone for patients, we did not see any posters placed in the waiting area and by reception.Following our inspection leaders told us that they had put posters in all consultation rooms, in the reception and the waiting area.

The provider had evidence of an action plan for improvements with a system and framework to measure performance. Arrangements were in place to safeguard adults and children from abuse, including individual roles and responsibilities for safeguarding leads that reflected legislation. Local requirements and policies were accessible to all staff.

According to the most recent GP national patient survey data the practice mostly made sure people were at the centre of their care and treatment choices.

The provider shared feedback collected from people through the Friends and Family test, which was overall positive. The dates were unspecified, so it was unclear when the feedback was provided.

From complaints received into CQC, people told us they felt that sometimes the practice was unable to manage the clinical risks, for example medicines related concerns, and meet their care needs in a way that was safe and supportive. The provider was working closely with the PPG to improve communication channels with patients.

Staff told us that they were able to access the emergency equipment and emergency medicines easily. We saw evidence of this during our visit. There was regular checks of emergency medicines and equipment, including defibrillator and oxygen. Staff had also completed training in sepsis, basic life support and emergency procedures.

Leaders told us that the number of significant events relating to violence and aggression by patients towards staff had increased. As a result, the practice was keen to involve people to manage risks and listen to patient feedback to improve patient experience. The provider had identified a plan to implement an enhanced patient recall system for better appointment availability and disease monitoring. They were also keen to improve communication channels for patients. We identified that further work was required to involve people to manage risks.

During the remote clinical reviews, we found patients with long-term conditions, not always given appropriate safety netting advice to deal with risks that may occur. We found there was a lack of follow up within a short time frame after steroids given for an exacerbation of asthma. We found 48 patients had been prescribed 2 or more courses of steroids in the last 12 months. We reviewed 5 records and found that none of these patients had received a follow up within 1 week of steroids. This meant that there was a risk of these patients deteriorating due to their asthma and not being seen on time.Leaders told us that following the inspection they had introduced a new Asthma/COPD protocol and were working closely with the Clinical Pharmacist.

There was a new access/appointment policy that had been created and implemented in August 2024. A system had also been implemented to manage non-clinical staff absences and busy periods. There was a clear reception workflow poster to support non-clinical staff with triaging appointments. However, the provider did not have sufficient checks in place to ensure that receptionists carried out patient triage correctly, particularly when patients were being diverted to other services.

Since the previous inspection, staff told us that work had begun to improve the safety of the physical environment. For example, sharps boxes were stored and labelled correctly. From questionnaire feedback, staff told us that they had the necessary equipment required to perform their role and felt satisfied with the health and safety arrangements within the practice. Leaders told us that they ensured health and safety risk assessments were conducted and appropriate action taken. However, we found that some actions had not been taken.

Leaders told us that a safety goal was to improve emergency response times. To achieve this, they were going to conduct mock drills with staff to assert understanding of practice safety. We did not see any evidence that these mock drills had been conducted.

Overall, the provider had detected potential risks in the care environment, but we did not see evidence that they had taken steps to reduce this risk. For example, a store cupboard containing electrical equipment was reported to have raised room temperatures. There was no temperature monitoring of this room, despite there being medicines and other clinical equipment present.Following our site visit leaders told us that they now had a thermometer in place which is checked daily.

Fire risk assessments had been conducted and there were two designated fire marshals. These members of staff had completed fire marshal training.

Legionella risk assessments had been conducted.

Overall, the provider had implemented a range of risk assessments to ensure the premises were safe, however the concerns identified had not always been assigned to anyone for action.

Some people raised concerns that although they had seen improvements in the culture of the practice since our previous inspection, some people felt that staff were not always trained appropriately to respond to their immediate queries and appointments were not always booked with the most appropriate clinician.Following our inspection leaders told us that they had responded to this patient feedback and started to put in place new processes to improve care navigation.

There were gaps in the practices processes regarding effective supervision for staff who made clinical decisions. Staff told us that they would seek advice from a GP when required and felt that they would be supported. However, there was not an embedded formalised process.

We received mixed feedback from staff regarding if there was enough staff and appropriate skill mix to provide safe, high-quality care. Throughout our assessment we found that the provider did not always have effective processes in place to cover key personnel absence.

The practice was not able to provide assurances that recruitment processes were in place and effective. We reviewed 6 files and found gaps in all the files. During our site visit staff were not able to locate 2 of the clinical staff files that we requested to see. We reviewed these remotely after the visit. Following the visit the provider reviewed their processes and implemented a new system however, we found that there were still gaps. We found 1 out of 6 files did not contain proof of identity, 3 files did not contain satisfactory evidence of conduct in previous employment, 5 files did not contain any evidence of employment history, and 4 files did not contain any evidence of supervision or appraisal.

The provider did not have a process of ensuring they had recorded the vaccination status of staff in line with current guidance. 4 out of 6 of the staff files we saw did not contain a record of immunisation. The provider had provided assurances that this was in place following the assessment.

A Disclosure and Barring service (DBS) policy and Chaperone policy had been created in June 2024. Non-clinical staff who were chaperoning had DBS checks in place and had completed chaperone training. However, there were no DBS checks in place for the clinical staff files seen, despite their policy stating that this was a requirement. Leaders received feedback about this issue during the inspection and took immediate action.

A clinical supervision policy had been created in June 2024 however; we did not see evidence that this had been embedded yet. Leaders told us that staff' learning needs were identified through annual appraisals, team feedback, and clinical audits. However, we did not see any evidence that these had occurred.

We did not receive any concerns from patients specifically about infection, prevention, and control. Therefore, we did not receive enough evidence from patients to score this evidence category.

Staff had completed infection prevention and control mandatory training and told us that everyone is responsible for keeping the environment clean. Some staff we spoke with could not identify the infection, prevention and control lead. Staff had access to personal protective equipment (PPE).

We observed that spillage kits were available if needed.

The provider had created an improvement plan following our previous assessment and their additional inspections from the ICB. We found that most of the actions were still unresolved, but leaders were committed to addressing the actions.

The practice had received support about infection prevention and control from the local ICB and Primary Care Network since our previous assessment. However, there were still actions that needed to be addressed.

An Infection Prevention and Control policy and Infection Prevention Control Handbook had been implemented in June 2024. An IPC audit had been conducted in June 2024 and a waste management audit in May 2024. We did not see evidence that all of the actions had been acted on.

Although there was an identified lead for infection prevention and control, they had not received the correct level of training and oversight required for the role. After our onsite activity we were told that the lead for infection prevention and control role had been transferred to a different staff member. We did not receive any evidence that they had additional training or oversight.

Clinicians involved patients in decision making processes about their medicines including opioids (used for pain relief). We also found that structured medication reviews were being conducted regularly to ensure their medicines were safe and effective.

Staff told us there were processes for regular clinical supervision of their prescribing practices. Learning from medicine incidents was shared through various governance meetings. However, some staff lacked awareness of documentation regarding patient group directions (PGDs) and patient specific directions (PSDs). This meant that in some cases, the legal authorisation by a prescriber was not in place to allow staff to administer vaccines. We raised this with the practice, and assurances were provided to ensure appropriate actions had been taken.

Some medicines, for example vaccines, need to be stored in a fridge to make sure they remain safe to use. Medicines were generally stored safely, with daily temperature monitoring of refrigerators where vaccines were stored. Staff understood how to raise concerns if the temperature had become outside of the safe range. There were processes to manage prescription stationary and reduce the risk of misuse or diversion. However, on the day on inspection we found a medicine and some blank prescriptions unsecured in a drawer. The provider took immediate action.

The practice had policies in place to govern the safe use of medicines. PGDs were up to date, however not all staff who were administering medicines against the PGD had been authorised to do so. There were processes to ensure that repeat prescription requests were dealt with in a timely way. However, we found that there was a lack of oversight of the management and recording of controlled drugs (medicines requiring additional security measures due to their potential for abuse or misuse). We raised this during our visit and the issue was rectified immediately.

As part of the assessment a number of set clinical record searches were undertaken by a CQC GP specialist advisor. A sample of the records of patients with long-term health conditions were checked to ensure the required monitoring was taking place. These searches were visible to the practice, and staff were consistently running the searches. The searches showed that there had been an improvement in the management and review of patients prescribed controlled drugs (medicines which can cause harm if they are not used properly and can lead to dependence and misuse). Patients who were showing as overdue were being managed in a clinically appropriate way and the provider had clear oversight of their treatment.