The Limes Medical Centre

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

Since the last assessment, we found some improvements in the management of medicines and safeguarding processes. We found the leadership team needed strengthening to ensure they had clear oversight of potential risks. Processes for the actioning of incidents and significant events had now been embedded and learning was shared with the team.

At this assessment we found some health and safety risk assessments and an infection control audit had been completed to identify potential risks to patients or staff, but we identified potential risk during the onsite assessment due to the exceedingly high temperatures in the building which were impacting on both staff and patients. The practice had taken some action to improve processes, however we were unable to gain assurances that staff had completed training relevant to their role. Improvements were required in the security of prescriptions, staff recruitment, induction and training. We identified potential risks in the cold chain procedures for the storage of vaccines.

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.

Information reviewed demonstrated that people had opportunities to provide feedback and they knew how to make a complaint. We were unable to confirm that information was available in the practice due to the disarray of the noticeboards, however there was information on the practice website. We were told all complaints were documented in the complaints book, but on reviewing the complaints book we found there was no effective system in place, with some complaints wrote on pieces of loose paper, no evidence to demonstrate complaints had been acted on, investigated or actioned. At the time of the onsite assessment, we were told there were 20 outstanding complaints awaiting action.

Staff and leaders understood their duty to raise concerns and report incidents and near misses. However, we were unable to gain assurances that learning from incidents and complaints was shared with the practice team to identify learning and mitigate future risks. We reviewed a random sample of minutes of meetings and incidents that had occurred and found no evidence to demonstrate outcomes or learning had been shared with the practice team. For example: In January 2025 a sharps box was found not to have been labelled in line with infection control and clinical waste management guidelines. We checked the practice meeting minutes for both January and February 2025 and found no evidence this had been discussed. Due to the number of complaints still awaiting action, the provider was unable to demonstrate that learning was being shared with the team to mitigate future risks and improve patient satisfaction.

We were told there was a duty of candour policy in place, but on speaking with the management team we found inconsistencies in their knowledge on what duty of candour meant. We were therefore unable to gain assurances that the guidance would be followed appropriately.

Following the onsite visit, we received assurances that all staff had been informed that any complaint or incident must be reported by email to the management team. The complaints book was being removed to ensure that all complaints were received by the management team and actioned in a timely manner.

Leaders told us that clinicians made appropriate and timely referrals in line with protocols and up to date evidence-based guidance. On reviewing the clinical system we found the systems in place had improved and were assured that there were effective processes in place to ensure referrals were acted on in a timely manner.

We were unable to gain assurances that there was a system for processing information relating to new people including the summarising of new records. Staff told us that since the staff member had left in December 2024 who had this role, no-one had been employed or trained to do summarising of records. We found there were over 850 outstanding tasks which related to reports from NHS111 and Accident and Emergency which had not been actioned. Staff told us this had been reported to the leadership team, but no action had been taken.

 

Since the last assessment we found improvements had been made to the safeguarding registers. We reviewed a random sample of records and found they had been accurately coded when safeguarding concerns had been identified. Clinical system alerts were used to identify patients who were at risk of harm or abuse and there was effective management of the safeguarding registers.

The practice had a safeguarding lead for adults and children and policies in place to support staff in the event of a safeguarding concern. Staff we spoke with were able to share specific examples where safeguarding had been discussed but told us they would report any safeguarding concerns to the safeguarding lead.

Meetings were in place to discuss safeguarding concerns; however, we were unable to gain assurances that staff had completed safeguarding training relevant to their role. At the time of the assessment, we found the leadership team were unable to demonstrate systems were in place to manage staff training updates and they reported challenges in getting staff to complete the required training.
 

Leaders told us they were part of a primary care network and regular meetings were held with services to understand and manage risks.

Staff were aware of the actions to take if they encountered a deteriorating or acutely unwell person, however we were unable to gain assurances that staff had completed training relevant to their role.

There were some processes in place to ensure the practice prioritised care for their most clinically vulnerable, however we were not assured that people were told when they needed to seek further help and what to do if their condition deteriorated. For example, our clinical searches found people aged 65 years and over taking dual antiplatelet therapy had not been prescribed medicines to protect the stomach. The clinical searches potentially found 159 patients on these types of medicines. We reviewed a random sample of 5 patients and found none of the patients had been prescribed medicines to reduce stomach acid production.

There were some systems in place to support people who face communication barriers to access treatment (including those who might be digitally excluded). A hearing loop was available, however we found the staff were unaware of how to use it, if patients required the loop to aid them with their hearing needs.

We found some of the clinical staff were under pressure to carry out their roles effectively, due to the lack of support of one of the GP Partners. Evidence provided on the day of assessment showed people who needed urgent attention were not being seen by the senior members of the clinical team and staff were having to leave patients who required care until they had the capacity to see them. This posed a risk to the care and treatment of people and the health and wellbeing of staff being put under pressure to provide adequate care and support to people.

During the site visit we found the door lock to the upstairs offices was broken and the offices were easily accessible by the public. On the day of the onsite assessment, the outside temperatures were very warm. The practice had the heating on throughout the whole day which caused difficulties for both staff and people visiting the practice. The leadership team told us that they were having difficulties in getting the boiler fixed. We received complaints from people on the day and some people were unable to sit and wait for their appointments and had to stand outside. Staff were struggling throughout the day to work in such uncomfortable temperatures.

We were unable to gain assurances that staff had completed training in health and safety. We found staff in reception using high chairs which kept tilting forward and provided no support. Staff had brought in household cushions to provide them with extra support and make the chairs more comfortable. Staff were unaware if any formal risk assessments had been completed.

Portable appliance testing had been completed on some appliances in December 2024; however, others were dated as 2023. Following the onsite assessment we received assurances that all appliances had been safety checked. There was a lack of overall leadership to ensure this was safely maintained in a timely way to ensure risks were acted on and were being safely maintained.

 

There were procedures in place for the safe recruitment of staff, however on reviewing a random sample of personnel folders we identified gaps in the recruitment processes. We found no signed contracts for clinical staff and no evidence of indemnity insurance. Further reviews showed a member of the clinical team had signed their contract as an employee and as the employer. An induction checklist was present in the personnel folders we reviewed; however, there was no evidence to show who had supervised the completion of the induction and when the induction had taken place.

We found staff immunisation status records were not in place in any of the personnel folders we reviewed. One of the clinical staff had signed a disclaimer about having immunisations which was not appropriate as everyone who has direct contact with patients should be up to date with routine immunisations. This ensured the safety of both staff and patients. The practice manager was aware that there was not an effective immunisation programme and was in the process of asking staff to provide this information. We were told that the infection control lead had identified in December 2024 that staff immunisation was required. We were unable to gain assurances that there was any oversight of this from the clinical lead for infection control.

Since the last assessment a new practice manager and deputy manager had been employed. The practice had seen a number of staff leave over the past few months, this included both clinical and non-clinical staff. New staff had been recruited; however, we did not find that there were clearly defined roles to support staff in carrying out their roles effectively. For example, evidence provided showed staff were being asked to carry out roles they had received no training for. We did not gain assurances that the practice had clear processes in place to manage the training of staff.

There were processes in place for staff appraisals, however staff told us they did not feel they able to share concerns without fear of retribution.

There were staffing rotas, however this was not managed effectively. For example, staff told us that there times when they were left on their own and had to close the building.

The practice had implemented regular reviews to ensure staff employed in advanced clinical practice, for example, nurse practitioners were working within their competencies. However, staff told us they were not supported by all of the senior clinical leads which impacted on their workload.

The practice had an infection control lead in place who had undertaken an audit in December 2024. The practice had achieved 91%. An action plan was in place and recommendations had been acted on. For example: foot operated general waste bins to be provided in rooms. We were told that staff had completed training in infection control and prevention; evidence provided demonstrated staff had completed training in infection control and prevention relevant to their role.

There were policies and procedures in place and staff were aware of who the IPC lead was in the practice. We observed the general environment to be tidy. Sharps bins were available in all clinical rooms, but we found a sharps bin in the treatment room that had not been signed or dated. This had been noted as an incident in January 2025 and from the actions documented routine checks would be carried out. Part of the action plan was to send a reminder to all staff to ensure continued adherence to infection control standards and to prevent similar occurrences in future; however, this had not been followed up to ensure all staff were following the correct procedures.

At the last assessment we identified significant concerns in the management of people's care and the appropriate monitoring of people with long term conditions and those on high risk medicines. At this assessment we found improvements had been made, however further strengthening of processes were still required to ensure risks were mitigated.

The practice worked with the clinical pharmacists from the local Primary Care Network to monitor prescribing and management of patients on high risk medicines and other medicines which required monitoring. However, during the remote clinical review we identified potential clinical coding issues with a safety alert that had been issued concerning a medicine that had the rare but potential life threatening infection. The clinical searches showed potentially 3 people who were on this medicine who had not been made aware of the side effects. This was discussed with the provider to ensure a review was carried out.

We carried out a clinical search to identify people who had received a medication review in the past 3 months. The searches identified potentially 132 people in this category. We reviewed a random sample of 5 clinical records and found appropriate reviews had been carried out.

We found that vaccines were appropriately stored, however on the day of the site visit that there was only a data logger in the fridge, with no daily manual recording of temperatures. On reviewing the past temperature recordings we found some temperatures had been recorded as 14 degrees, this was outside the accepted range of 2-8 degrees. We discussed this with the leadership team and found there was a lack of knowledge of the requirements around vaccine storage and no evidence was provided to demonstrate actions had been taken when the temperatures had exceeded outside of normal range. We were told that the practice had been informed that they were not required to record daily temperatures and the data logger was sufficient. We queried this with the Integrated Care Board and found there had been a probable miscommunication and the practice had not been advised to stop manual recording. This was implemented again to ensure the safe storage of vaccines.

We found all the recommended emergency medicines and equipment were available and were regularly checked by the clinical team.

The storage of blank prescriptions was not effective to ensure they were secure and monitored. We were told by the management team that blank prescriptions were not used in practice anymore and everything was done electronically, but when speaking with staff we found that blank prescriptions were still being used, however this were not kept in a secured location. We informed the management team of our findings and received assurances that action would be taken.