Archived: Seaforth Farm Surgery

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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 looked for evidence that people were protected from avoidable harm.

As our last inspection, we rated this key question as Requires Improvement. At this inspection, the rating remains the same.

The service had made insufficient improvement and remained in breach of legal regulation in relation to safe care and treatment, and staffing.

This service scored 47 (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 did not have a proactive and positive culture of safety based on openness and honesty. They did not investigate or report safety events effectively. Lessons were not learnt to continually identify and embed good practice.

Staff knew how to identify and report concerns, safety incidents and near misses. However, feedback from staff showed that some remained fearful about speaking up and feared negative consequences.

The service did not always thoroughly investigate safety incidents and identify actions to prevent recurrence. We found significant events forms did not always contain detailed information regarding incidents which had occurred; supporting documentation was not clear to demonstrate learning identified; and there was limited evidence to demonstrate that learning was effectively shared and disseminated to the wider team. We reviewed a significant event form relating to urine samples being returned to the service as they had not been labelled or requested properly. The incident form included limited detail and did not identify learning or actions taken. We reviewed a separate action log which the service maintained to track actions from significant events. There was an entry that seemed to relate to this incident, although it did not include the incident reference number and the dates did not match. The entry noted that urine sample protocols would be discussed at a meeting on 8 October. During our inspection, we saw that a new protocol had been created. We were told it had been shared with staff through the service’s intranet. However, not all staff we spoke with were aware of it and there was no evidence the protocol had been shared or discussed in relevant staff meetings.

The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. We saw evidence that some appointments were being moved or cancelled by one of the partners without clear reason delaying people’s access to care. People were not always informed about these changes in advance. We were told this had at times created confusion and frustration for people.

We found improvements in the way the service managed test results and urgent referrals. The service had cleared the backlog of results and had subsequently processed results and referrals in a timely way.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

The service did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

The service had introduced a scope of practice for each of the clinicians employed in advanced clinical roles. However, we found evidence that these clinicians were still working outside of their agreed scope of practice. For example, one independent prescriber (that is, not a doctor) was prescribing a medicine for attention deficit hyperactivity disorder (ADHD) without a shared care protocol being accessible in the clinical notes. This is not in line with national guidelines and was outside of their documented scope of practice.

We were told that the service had introduced auditing of prescribing practices for clinicians working in advanced clinical practice and non-medical prescribers. However, these audits were failing to identify ongoing issues with staff working outside their scope of practice.

Clinical supervision was not effective and failed to identify areas for development or where clinicians were acting outside of their agreed scope of competence. For example, we found cases where medical associate professionals had not managed care or advised people appropriately, but this had not been discussed with or picked up by their supervising GP. We found cases where medical associate professionals had reviewed abnormal pathology results which was outside their scope of competency, and this had not been identified as a concern by their supervising GP. We found that a medical associate professional was reviewing spirometry results without having the necessary training to do so. Again, this was outside their scope of practice.

The service had not ensured appropriate recruitment checks were completed prior to staff commencing work. We found one doctor had been interviewed after they had been offered the role in the service. This doctor was not on the NHS performers list when they started to work at the service, and a risk assessment had not been completed.The NHS performers list is an official register run by NHS England. Doctors (GPs), dentists, and optometrists must be on this list if they want to provide primary care services for NHS patients. The list helps make sure these professionals are properly trained, qualified, and safe to treat the public.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

The service did not ensure that medicines and treatments were safe and met people’s needs, capacities and preferences.

The service had failed to improve the quality of medicine reviews. We found medicines reviews did not always contain necessary information to support continued prescribing. Information was not always available to demonstrate what was considered as part of the review; whether interactions of prescribed medicines had been discussed and considered with the person; or include a record of potential risks and actions to be taken. In 2 cases we reviewed, the reviews had failed to consider documented information in the clinical record that should have triggered further follow-up, leaving people at risk.

Improvements were still required to ensure staff had the necessary authorisations to administer medicines. We found Patient Group Directions (PGDs) were still not always authorised correctly. For example, staff had been added to some PGDs after they had already been authorised by the GP. (PGDs are legal rules that enable certain qualified healthcare professionals administer specific medicines to certain groups of people without the person needing to see a prescriber first.)

However, the service had made some improvements. They had improved their systems to manage and respond to safety alerts and medicine recalls.

The service had improved its monitoring of emergency medicines. These were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines, and vaccines. Staff stored medical gases, such as oxygen, safely.