Severn Valley 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 people were protected from abuse and avoidable harm. At our last assessment, we rated this key question as Good. At this assessment, we have rated the service Requires Improvement for Safe as not all systems and processes for medicines management were operating effectively. For example, we identified the process for medication reviews was not consistent with some reviews only coded on the clinical system with no detail or commentary on what had been reviewed; not all patients prescribed medicines which require monitoring had received necessary blood tests; and safety alerts were not always actioned in line with guidance.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice had processes for staff to report incidents, near misses and safety events. The practice had a positive culture of safety and leaders encouraged staff to raise concerns when things went wrong. Staff felt there was an open culture, and that safety was a top priority.

Lessons were learnt to continually identify and embed good practice. Learning from incidents and complaints was discussed in meetings and resulted in changes that improved the service.

The vast majority of patient feedback we received indicated that patients felt supported to raise concerns and felt staff treated them with compassion and understanding.

The practice worked with patients and healthcare partners to establish and maintain safe systems of care. Staff worked to facilitate continuity of care, including when patients moved between services. There were protocols in place for managing incoming correspondence into the patient’s medical records. Patient referrals to specialist services were documented in the referrals systems and patient record. We found referrals were managed in a timely manner.

Safeguarding policies and processes were in place to keep people safe and safeguarded from abuse. The practice had a safeguarding lead, and all staff had completed the relevant safeguarding training for their role and shared concerns quickly and appropriately. The practice maintained a list of vulnerable adults and children and acted on concerns working in partnership with other organisations. Clinical system alerts were used to identify people who were at risk of harm or abuse including household contacts. There were systems in place to respond to concerns and act on correspondence. For example, they followed up children who failed to attend their appointments or were frequent attenders to the accident and emergency department. Safeguarding meetings were held on a regular basis to review people at risk which included external professionals as required.

Emergency equipment was available and maintained. Systems were in place to check the emergency equipment and medicines regularly. Staff could recognise a deteriorating patient and knew what action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated. There were processes in place to ensure care was prioritised for their most clinically vulnerable patients.

The practice detected and controlled potential risks. They made sure equipment, and facilities supported the delivery of safe care and met people’s needs. Systems were in place for the checks of fire alarms, fire extinguishers and fire evacuation procedures. Portable appliance testing was completed annually to ensure equipment was safe to use. The practice had a legionella risk assessment in place that showed the risks were properly managed. There was a business continuity plan in place which was monitored and reviewed.

The practice made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met patients’ individual needs.

There were a range of clinical and non-clinical roles within the practice. We found training was up to date, learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence. Staff were positive about the support, training and development they received.

Safe recruitment practices were followed. We reviewed 5 personnel files and found appropriate checks such as previous employment record, proof of identity and references had been completed, and staff immunisation status records were in place.

The practice 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 (IPC) lead and all staff had completed relevant training. Risk assessments and audits were completed, and actions taken to mitigate risks. Clinical waste procedures were in place. The practice had effective oversight of the external cleaning company to ensure cleaning schedules were followed and cleanliness met the required standard.

Medicines were stored securely and at appropriate temperatures. Refrigerators used to store vaccines and medicines were monitored to ensure temperatures were maintained and products were appropriately stored within them. Staff regularly checked stock levels and expiry dates for all medicines, including emergency medicines. There were Patient Group Directions in place which relevant staff worked to. The primary care network pharmacy team supported the practice with medicine reviews for patients with co-morbidities and polypharmacy.

Prescribing data reviewed as part of our assessment found practice performance was in line with national averages for Pregabalin and Gabapentin medicines (primarily anticonvulsant drugs, also prescribed for pain); psychotropic medicines (used to treat various mental health conditions); hypnotic drugs (used for the management of severe insomnia); and antibiotics.

As part of our assessment a Care Quality Commission GP Specialist Advisor undertook searches of patient records on the practice’s clinical system. Our clinical records review identified not all systems and processes for medicines management were operating effectively. We found the following:

Medication reviews: We reviewed a random sample of 5 medication reviews out of a total of 313 reviews that had been completed for patients in the previous 3 months. We found 2 of these 5 medication reviews had been coded but lacked any information, such as monitoring arrangements or details about what had been reviewed or changed as a result of the review.

Methotrexate (an immune system suppressant drug): We identified 104 patients and found that 8 had not received the required monitoring in the last 6 months. Of these 8 patients, we reviewed the records of 5. We found one patient had not received all of the required blood tests. Following our assessment the practice provided us with evidence from the Integrated Clinical Environment (ICE) system to demonstrate the patient had received the necessary blood tests, however we were not assured these blood test results were checked by the clinician prior to prescribing as there was no evidence documented within the EMIS system that this had been done. We also identified3 patient records which had not been appropriately coded with regards to their blood tests. In addition, we found for all of the patient records we reviewed, the day of the week the medicine should be taken was not indicated. As the prescribed dose of Methotrexate should be taken once weekly on the same day each week, this day should be documented and clearly communicated to the patient.

Amiodarone (a drug used to treat or prevent heart rhythm disorders): We identified 15 patients and found 8 who had not received the required monitoring. Of these 8 patients, we reviewed the records of 5. We found none of the patients had received blood tests for magnesium. Specialist Pharmacy Service guidance states magnesium blood testing is required every 6 months for patients prescribed this medicine. In addition, we found there was a lack of electrocardiogram (ECG) results in these patient records.

Non-steroidal anti-inflammatory drugs (NSAID - used to reduce pain, fever, and inflammation) prescribed to patients over 65 years of age; and antiplatelet drugs (used to inhibit the formation of blood clots) prescribed for patients over 75: We identified 157 patients out of 535 who had not been prescribed Proton Pump Inhibitor (PPI) drugs and reviewed the care records for 5 patients.PPIs are a group of medicines that decrease stomach acid production. National Institute for Care and Health Excellence (NICE) guidance recommends prescribing PPI drugs for elderly patients taking NSAID or antiplatelet drugs to reduce the risk of gastrointestinal bleeding. Of the 5 patient care records reviewed, we found 4 patients had not been prescribed PPIs and had not declined being prescribed these drugs or been identified as not being able to tolerate the drug.

Safety Alerts: There was a process in place for recording and sharing medicine safety alerts. Safety alerts were discussed in clinical meetings. Our review of clinical records however indicated that safety alerts were not always actioned in line with guidance. For example, not all patients prescribed Mirabegron (a medicine that eases the symptoms of an overactive bladder) had received an up-to-date blood pressure check. Mirabegron is contraindicated in patients with severe, uncontrolled high blood pressure. In addition, our clinical records search identified numerous out-of-date safety alerts on the clinical system. Out-of-date safety alerts could potentially lead to incorrect actions or missed opportunities for patient care. Clinical safety alerts should be reviewed and deactivated if no longer relevant, and the clinical system’s triggers for alerts should be checked and adjusted as needed.

As part of our assessment, we gathered patient feedback via our ‘Give Feedback on Care’ process. We received feedback from a total of 318 patients. 258 patients were complimentary about the care and treatment they received, and 60 patients provided negative feedback about the practice. A number of patients expressed dissatisfaction with test results being communicated with them and prescriptions not being processed in a timely way.