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 assessed a total of 5 quality statements from this key question. We have combined the scores for these areas with scores based on the rating from the last inspection, which was good. We found breaches of regulation for this key question and have told the provider to take action. Significant events were not well managed, the practice did not assure themselves of staff competency when undertaking minor operations and prescribing medicines. Fire and water safety systems where not up to date. The practice did not have an effective system for recording and acting on safety alerts.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not receive any feedback about the learning culture from people who used this service.

Staff knew how to identify and report concerns, safety incidents and near misses. However, staff told us that if they did raise concerns, these were often ignored or dismissed. They told us they didn’t receive feedback about the learning or action from the significant events they did report. Leaders told us that significant events and complaints were discussed in meetings, but when we looked at meeting minutes, and reviewed events we found this was not always the case. Leaders acknowledged that oversight of the process for dealing with significant events and complaints needed to be improved.

Staff told us that they did not always feel part of the review process, and some said they had felt excluded from the meetings and unable to contribute. This meant the practice could not consider all relevant information to identify areas for learning and improvement.

Whilst the practice had a policy and procedure for dealing with significant events this was not consistently followed and lacked detail on what constituted a significant event. Forms used for reporting significant events were incomplete which meant there was insufficient evidence to show whether enough information gathering or investigations into root cause had taken place. It was unclear who was responsible for actions and whether the actions had been completed or followed up. Appropriate action and lessons learned were not always identified and key members of staff were not always involved in the review. We looked at the practice’s complaints and found a similar concern. For example, whilst we saw a documented discussion paper prepared for a meeting to review a significant event, the clinical meeting did not demonstrate a full review of the incident took place. No action plan was set out to ensure such incidents would be prevented or reduced in the future. Minutes of meetings outlined complaints but did not set out the steps to action and how the outcomes of these actions would be reviewed.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not receive any feedback about safeguarding from people who used the service.

Staff were up to date with safeguarding training at the appropriate level for their role. They could tell us who took the lead in safeguarding within the practice and what steps they would take to raise or act on concerns.

We were told that prior to our assessment, the practice had identified the need to have a clear embedded approach to safeguarding meetings for children alongside the regular multidisciplinary meetings. However, there was no evidence to demonstrate that this had been implemented.

We did not receive any feedback about safeguarding from partner organisations.

There was a system to follow up on children who were not brought to their appointment, either at the practice or secondary care.

We found that systems for ensuring safeguarding registers for children were kept up to date needed to be strengthened. There was limited evidence that children on the safeguarding register were regularly discussed and reviewed.

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.

Staff responsible for monitoring fire safety and health and safety told us that both the main and branch surgery had health and safety risk assessments carried out in 2023. They told us that actions identified in these health and safety risk assessments had been completed. However, on review, we found that the fire risk assessment was not up to date.

Following our assessment the provider told us what actions they had taken including the submission of an updated risk assessment undertaken in September 2024. This risk assessment identified areas that required action and was accompanied by the providers action plan to address these concerns.

During our assessment we observed the environment to be safe from visual hazards relating to health and safety and fire. For example, fire exits were clear and free of obstructions. However, we observed that health and safety risks were not always reviewed in line with the practice’s risk assessments.

Contracts were in place to ensure the premises were maintained. Health and safety risk assessments and audits had been undertaken and risks identified had been addressed in most cases. However, actions taken to monitor the risk of Legionella did not follow guidance. Appropriate action was not always taken when temperatures consistently fell below accepted safe levels for hot water storage and delivery. Leaders told us that a problem had been identified with the equipment used for testing that may have accounted for incorrect readings. However, we also identified that practice staff responsible for monitoring temperatures relied on practice monitoring guidelines that set out the incorrect temperature values to be used as a safety level.

There was a business continuity plan in place which was monitored and reviewed.

The results of the national GP patient survey showed that respondents had trust and confidence in the professionals they spoke to. Patients felt they were treated with care and concerns and were listened to.

Staff also told us that they were able to complete required training. We were told that support was provided by colleagues and managers, however, they felt arrangements for clinical supervision were insufficient. Staff did not always feel they could get the support they needed to undertake their role.

Leaders told us they had systems to ensure safe levels of staffing. The practice had regular locum and salaried GPs to support clinical care.

There was limited evidence to show how the practice assured the competence of staff employed in advanced clinical practice. Records of clinical supervision lacked the detail required to demonstrate this. The scope of staff employed in advanced clinical practice was unclear and unspecified. The practice had not implemented processes to monitor staff conducting minor operations. The practice could not demonstrate they had assessed staff as competent before they conducted these procedures or that there was a process for ongoing monitoring to ensure procedures were effective, safe and conducted in line with national guidance.

We did not have specific feedback on infection control from people who used this service.

We spoke with the infection control lead for the practice. They told us they had received training for their lead role and that they oversaw a programme of regular infection control audits. Staff and leaders told us that training on infection control was part of their essential training requirements.

We observed that the premises were clean and tidy and free from clutter. Cleaning logs were in place and appropriate systems were in place for the cleaning of equipment.

Minor operations were carried out from a room that was clean with suitable flooring and furnishings. Single-use equipment for minor operations was provided and in date.

There was an effective approach to assessing and managing the risk of infection. With clear roles and responsibilities. However, systems for ensuring staff had appropriate and up to date vaccinations were insufficient. We were told that work was underway to improve this.

Arrangements for assessing the risk of legionella were insufficient. Records were unclear and not underpinned by appropriate guidance.

The practice undertook regular audits of infection control. Audits carried out in March 2024 at both sites set out areas requiring improvement in an action plan. This included significant concerns with the cleaner’s storage area that our observations confirmed had been addressed. The practice scored 94.6 out of 100 in their latest infection control risk audit.

We did not receive any feedback from people who used the service about medicines. However, our clinical searches showed that risks to people’s health were not always discussed with them when new medicines were prescribed, and patients were not always involved in their medicine reviews.

Staff told us they felt confident managing the storage, administration and recording of medicines. Staff managed medicines-related stationery appropriately and securely. Staff told us they followed protocols to ensure they prescribed all medicines safely, and ensured people received recommended medicines reviews and monitoring. However, this was not always evident in the records we saw.

Staff managed medicine stock safely and regularly checked the stock levels and expiry dates for all medicines, including emergency medicines, vaccines, and controlled drugs. However, the practice did not hold all emergency medicines recommended by national guidelines and risk assessments were not in place to determine the range of emergency medicines held. For example, we observed that the practice did not hold a medicine used to prevent or reduce nausea and vomiting. A medicine for the treatment of Croup in children was also not held in at the recommended dosage. In addition, this medicine was stored separately in the nurses’ cupboard and not with the emergency medicines which could affect timely access to the medicine. The impact of this had not been risk assessed. We observed there was medical oxygen and a defibrillator on site. There were no child defibrillator pads and no risk assessment for this. Leaders told us the provision of child pads had been discussed with the practice’s resuscitation trainer and a decision was made to use the adult defibrillator pads. However, there was no record of this discussion or assessment of risk.

There was no evidence at time of inspection to show how the practice had assessed the prescribing competence of non-medical prescribers. They were unable to provide evidence of regular reviews of prescribing practice supported by clinical supervision.

We found that the provider did not always have an effective system to manage and respond to safety alerts and medicine recalls. For example, advice was not recorded on the patient record on the risks of taking combinations of medicines and the risks associated with the use of medicines for the treatment of diabetes.

Patient group directions (PGDs), a legal framework that allows some registered health professionals to supply and/or administer specified medicines to a pre-defined group of patients, without them having to see a prescriber (such as a doctor or nurse prescriber) were not always authorised in line with national guidance. Nurses were added onto the record after the directive had been authorised by the GP. We had identified this as a concern at a previous inspection, however necessary improvements had not been made.

Our clinical searches showed that in most cases patients’ health was monitored in a way that ensured the safe prescribing of certain medicines. Areas for improvement were identified during our assessment, and these results were shared with practice to follow up. For example, we reviewed a sample of five patient records and found that two patient medication reviews lacked sufficient detail and evidence of patient involvement in this process.

The provider was unable to provide assurances that patient outcomes were monitored effectively. They had not ensured patients effected by medicine alerts received the necessary support and guidance. Patients had not been advised of potential risks which meant they were unable to make informed decisions about their care and treatment. For example, we saw an alert about the risks associated with the combination of a medicine for high cholesterol and a medicine for high blood pressure. Nine patients were identified, and we looked at 5 records in more detail. We found no evidence that advice was given to patients about the potential risks as advised in the Medicines and Healthcare products Regulatory Agency (MHRA) alert published in 2014.