Redgate 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 all quality statements in the safe key question.

Our rating for this key question remains good. 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. There were systems and processes to monitor people’s prescribed medicines that required additional monitoring. However, we noted some gaps in medicine monitoring during our clinical searches. The service addressed these immediately and instigated further systems and processes to reduce the risk of this recurring. We identified some discrepancies in the service’s Disclosure and Barring Service (DBS) check process and the service took immediate action to address this by introducing a new process to ensure compliance.

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 provider 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. Significant events and complaints were discussed in meetings and learning was shared to improve people’s care. Meeting notes were shared with all staff, including those who could not attend. We saw evidence that the service managed complaints and incidents in line with the above processes. For example, a patient who took a high-risk medication incorrectly suffered an adverse effect requiring hospital admission. The service identified the underlying causes, which were due to a combination of factors, including a lack of escalation by the service when the patient did not attend for blood monitoring. The service implemented an action plan to strengthen the detection and follow-up for patients who missed monitoring for the high-risk medication. The learning was shared in a staff meeting.

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.

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 way. The service had a process to ensure the review of test results during staff absence. 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. There were systems for processing information relating to new patients.

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.

Staff had undertaken up-to-date safeguarding children and vulnerable adults training at the appropriate level for their roles. Staff explained to us the systems and processes to keep people safe from abuse and they felt confident in raising concerns. Staff knew who the safeguarding leads were. The service had a designated member of staff to manage the administrative work relating to safeguarding. Alerts on clinical records flagged people with safeguarding concerns, including their household members.

The service maintained a list of vulnerable people and acted on concerns, working in partnership with other organisations. The service regularly discussed safeguarding concerns within the service at clinical meetings and externally with school nurses, health visitors, midwives and the local Integrated Care Board (ICB) when required. The service also engaged in safeguarding training and meetings organised by the local ICB.

The service had clear systems and processes to keep people safe and safeguarded from abuse.The service had a safeguarding policy for children and adults which was accessible to all staff. However, we found the policy lacked details on internal safeguarding processes. The service took action immediately and updated the policy to reflect the current processes. The updated policy was shared with all staff.

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

Staff were up-to-date with their basic life support training. All staff, including non-clinical staff, had completed sepsis or sepsis awareness training. Staff could recognise a deteriorating person and knew of action to take. Staff could summon help quickly in an emergency using the panic buttons on the computer system or on the phone in the practice. People received advice on risks relating to their condition and the actions to take if their condition deteriorated.

Emergency equipment was available and maintained with regular checks. The service did not stock all the recommended emergency medicines in line with guidance and there was no evidence regarding the reason for this. The service took action and provided us with evidence to demonstrate they had completed a risk assessment to address not stocking certain medicines.Not all staff were familiar with the emergency equipment and where the equipment was kept. The service took action to remind all the staff regarding the placement of emergency equipment and arranged a refresher training session for the next whole practice meeting.

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. The facilities and premises were appropriate for the services being delivered. Fire equipment checks and fire drills were documented. Electrical equipment was tested to ensure it was safe to use and equipment was calibrated for accuracy. All staff were up-to-date with fire safety and health and safety training. Lead roles for health and safety were clearly defined. 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. Staff were required to work in pairs during the service’s daily opening and closing routines to ensure safety and provide support. Health and safety risk assessments were carried out and appropriate actions were taken where needed.

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

There was a range of clinical and non-clinical roles within the service. Most staff expressed there were enough staff to provide safe and high-quality care. Safe recruitment practices were generally followed.However, the DBS policy stated that staff who did not require a DBS check would complete a self-declaration form as part of the recruitment check. This was not followed. The service took immediate action to rectify by requesting those staff to complete the forms and implemented a new process that all staff had to submit a self-declaration form annually with monitoring for compliance. Staff had regular appraisals and were able to discuss their learning needs. 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 towards enhanced nurse practitioner or general practice assistant. Staff told us the leaders were supportive and approachable. However, not all clinical staff had regular clinical supervision sessions and the clinical supervision was not documented. Following the assessment, the service developed a new clinical supervision policy and implemented a process to document the clinical supervision for all clinical staff. There were no competency checks for clinical roles. The service developed a new process to check clinical competencies at induction and appraisals. The service set up the mandatory training requirement on their online learning platform and all staff were up-to-date with their allocated mandatory training. However, the allocated training on the system was different from that in their training policy. The service acknowledged the discrepancy. The service discussed and reviewed the training requirements in a clinical meeting, and the training policy was updated. New mandatory training was identified and assigned to certain staff groups. The staff were required to complete the training within a set time frame.

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. An isolation room was available if people were suspected of having an infectious disease.

The service had a designated infection prevention and control (IPC) lead, and all staff were aware of who the person was. All staff had received relevant IPC training in line with their roles and responsibilities. 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 on the day of inspection. Cleaning schedules were followed and the service regularly reviewed the cleaning audits of the external cleaning company and discussed with them 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. External clinical waste bins were locked and stored in a secure area. There was a process to record staff immunisation but there were some gaps in the monitoring of staff immunisation status. Following the site visit, the service provided assurance that they contacted the staff to clarify the missing immunisation history and would follow up as appropriate. IPC risk assessments and audits were completed, and actions were taken to mitigate risks. However, we observed carpet use in some consulting rooms and some chairs in the waiting area were not wipeable which could pose IPC risks. These were not covered in the existing IPC risk assessment. The service immediately carried out the risk assessment and implemented risk mitigation measures.

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. The service regularly audited non-medical prescribers (healthcare professionals who can prescribe medicines but are not GPs) to ensure medicines prescribed were necessary, correctly prescribed and followed up when needed. Vaccines were appropriately stored and monitored in line with national guidance to ensure they remained safe and effective.The service shared an example of a vaccine fridge failure incident which they managed according to their established protocol. The service investigated it as a significant event and shared the learning with staff. The service had a process for authorising staff to administer medicines including Patient Group Directions (PGDs - a written instruction for the supply and/or administration of a named licensed medicine for a defined clinical condition) or Patient Specific Directions (PSDs - a written instruction from a doctor or other independent prescriber for a medicine to be supplied or administered to a named patient). However, we reviewed a sample of PGDs during the site visit and found they had not been completed correctly in line with guidance. After the site visit, the service rectified the issue and we saw evidence that the PGDs were completed correctly. The service also reviewed and updated the PGD policy to reflect the requirements. Blank prescription stationery was securely stored in a locked filing cabinet. However, the blank prescription stationery was not always kept secure when in use during clinical sessions. To address this, the service carried out a risk assessment, implemented risk mitigation measures and updated the prescription security policy.

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 identified shortfalls in the review and monitoring of people prescribed certain medicines. We identified 336 patients who had medicine reviews in the last 3 months. We sampled 5 patient records to look at the quality of medicine reviews and found all of them contained insufficient details. The service followed up with the identified patients. The service developed an action plan for people requiring medicine reviews who would be identified through regular searches, and all reviews would be documented using a standardised template to ensure consistency and quality. Our clinical searches identified 30 patients who had been prescribed bisphosphonate (medicine to treat or prevent osteoporosis) for at least 5 years. We sampled 5 patient records and all of them had not been reviewed in line with national guideline. The service reviewed the group of patients and managed as appropriate. The monitoring of bisphosphonate use would be incorporated into the medicine review process to mitigate future risks.

Prescribing data showed the prescription of gabapentinoids (medicines prescribed for treatment of epilepsy, neuropathic pain or generalised anxiety disorder but with risk of misuse or dependence) and antimicrobials was lower than the national average.