Gough Walk 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 that people were protected from abuse and avoidable harm. Staff felt safe to raise concerns. Incidents were investigated, and people were protected through effective risk management. Facilities and equipment were clean, well-maintained, and met practice needs. Managers ensured staff received regular training and appraisals to support high-quality care. Staff mostly managed medicines safely. However, staff did not always carry out patients’ blood tests and physical checks prior to a review or prescription being issued. This is the first inspection for this service since its registration with CQC. This key question has been rated as Requires improvement.

This service scored 59 (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 systems to learn from incidents and improve services. Staff felt able to raise safety concerns, investigated events, and shared learning to help embed best practice. The whole team discussed and learnt from clinical issues. The service had weekly clinical huddles to discuss any cases of concern and we saw these meetings were recorded. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. The service had a duty of candour policy in place. A member of the Patient Participation Group confirmed the provider took concerns seriously and acted to improve the service.

The service had a system in place to receive, share and act on safety alerts. We saw evidence of clinical audits in response to Medicines and Healthcare products Regulatory Agency (MHRA) alerts. However, the service had not ensured all patients prescribed medicines subject to an alert were identified and managed appropriately. For example, 4 patients prescribed medicines used to treat depression and or anxiety disorders, had not received appropriate monitoring. Clinicians had overlooked an older MHRA alert despite an alert flagging their patients’ records. (MHRA alert December 2014). There was no record that these 4 patients had been informed promptly of any potential adverse effects of the medicine they were taking.

Three of the four patients were under secondary care, with medication initiated and maintained by the cardiology clinic. The fourth patient’s treatment was initiated by the mental health team and ongoing prescribing managed by the practice. Leaders said no concerns about risks were raised by specialists at the time of prescribing. Following identification of this issue, the service acted to review patients and arranged dose reductions or antidepressants where appropriate.

Leaders told us the pharmacists would run regular searches to ensure patients on metformin do not have an estimated glomerular filtration eGFR below 30 (a blood test to check how well a person’s kidneys are filtering waste and excess fluid from their blood). However, our clinical search identified 762 patients on metformin. The search identified 3 patients on Metformin with eGFR below 30 who had not been managed appropriately in line with NICE guidance. Prescribers had not acted on the MHRA alert to stop metformin when eGFR is below 30, the risk being lactic acidosis which can be potentially life-threatening. Clinical searches identified that where patients were under close monitoring by the renal team post-transplant; we found the practice were not routinely coding blood test results on patient records. Leaders told us they would take action to ensure blood test results were coded on patient’s EMIS record. When we raised this with leaders, they immediately responded and took action to stop the medication for the two other patients. Leaders also told us the service will run regular searches to ensure patients on metformin do not have an eGFR below 30.

The staff made sure there was continuity of care, including when people moved between different services. The service had robust systems in place to ensure information was effectively shared across teams and agencies, enabling the delivery of safe, coordinated care. There was a system to ensure referrals to specialist services were documented and contained the required information. The service had processes in place to monitor urgent (2 week wait) patient referrals to secondary care and ensured all patient referrals were followed up.

Communications from secondary care, such as discharge summaries, were processed efficiently to ensure continuity of care. We reviewed workflow processes which demonstrated all test results were managed in a timely way, ensuring that abnormal results were acted upon without delay. The service had a new patient registration policy and there were systems in place for processing information relating to new patients.

The service had systems and processes in place to safeguard adults and children from abuse. Any concerns were addressed in collaboration with partner agencies to ensure a coordinated approach. The service had leads for safeguarding adults and children. All staff we spoke with were aware of who the lead was and how to escalate any concerns they had. They demonstrated how they would act if they suspected a patient’s safety was at risk. Training records we reviewed showed all staff had received safeguarding training appropriate to their roles and responsibilities.

Staff reviewed and maintained safeguarding registers for both children and adults. Safeguarding alerts were added to the clinical record system when relevant, ensuring that all team members could identify any ongoing concerns and could act accordingly.

Staff had identified risks within the care environment, ensuring equipment, facilities, and technology supported delivery of safe care. The service was equipped to deal with medical emergencies (including suspected sepsis) and staff were suitably trained in emergency procedures. Patients were advised on risks related to their condition and actions to take if their condition deteriorated. All staff had been trained in basic life support.

The service operated an online consultation service to help triage patient queries and appointment requests. The service had guidance for staff to identify and escalate risk to an appropriate clinician. The service had developed an on-call duty GP rota, to enable the prioritisation of patients with urgent needs.

The service detected and controlled potential risks in the care environment, ensuring equipment, facilities, and technology supported delivery of safe care. Contracts were in place to ensure the premises were maintained to keep everyone safe. Comprehensive health and safety audits and risk assessments, including electrical, gas, and Legionella had been completed within the past 12 months, with all identified risks addressed. The service had a business continuity plan which was regularly reviewed to manage major service disruptions. Staff reported no concerns regarding health and safety arrangements.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. Leaders followed safe recruitment processes.

Leaders used an electronic management tool to monitor completion of staff training. We found most staff were up to date with mandatory training. Learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence. Staff participated in monthly protected learning time (PLT) sessions focused on learning and professional development. Most staff had received an annual appraisal. Where people had specialist needs, staff had received training on how to support autistic people and people with a learning disability.

Clinical staff and non-medical prescribers received support and supervision and meetings were routinely documented. We saw that where clinical consultations had been discussed with a GP, this was recorded in the patient record. We reviewed a sample of consultation notes of non-medical prescribers, and we found the consultations were of good quality and appropriate.

The service effectively assessed and managed infection risks. Staff detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. At the time of our assessment, the IPC lead was not available for us to speak with. The facilities and premises were clean, and systems were in place to prevent the spread of infection. Personal protective equipment (PPE) was well stocked and placed appropriately throughout the building. Staff had received training relevant to their roles. Cleaning schedules were in place, and regular infection control and cleaning audits were conducted to maintain standards. Waste, sharps, and clinical specimens were managed carefully to keep everyone safe.

Staff vaccinations were not always kept up to date in line with the latest UK Health Security Agency (UKHSA) guidance. For example, we found records of staff immunisation were partially documented for 3 members of staff, two of which were clinical staff; this risk had been identified during the NHSE Infection prevention and control audit in May 2024 but had not been responded to. We did not see any risk assessments documented for these staff members. There was a clear system for reporting infection concerns to the relevant agencies, such as for notifiable diseases.

Medicines were not always prescribed, supplied or administered in line with legislation or national guidance. Some staff did not consistently follow prescribing protocols, which affected safe practice and timely reviews.

In several of the medicine reviews examined, consultation notes lacked sufficient information to demonstrate safe clinical decision‑making. These issues were identified through clinical record searches carried out by a CQC GP specialist adviser, with the provider’s consent. The searches, which were visible to the service, assessed whether care and treatment were being delivered in line with current legislation, standards and evidence‑based guidance.

For example:

• Patients prescribed oral anticoagulants had not received appropriate monitoring. This meant patients were at risk of not being recalled, followed up and reviewed which could result in serious risk to their health and wellbeing. For example, a clinical search identified 103 patients prescribed a direct-acting oral anticoagulants DOAC (medicines used to thin blood) of whom 48 were frail or over 75 years of age and 20 patients (42%) had not had monitoring done at the correct interval (every 4 months). Leaders told us they had reviewed these patients to ensure that patients on DOAC medicines continued to be safely monitored appropriately in primary care.

• A clinical search identified 19 patients prescribed Disease Modifying Antirheumatic Drugs (DMARDs). We reviewed 5 patients taking methotrexate and found that, although 4 were under secondary care, none had the day it should be taken recorded in their notes. Best practice requires documenting the day of administration, and an MHRA alert from 23 September 2020 reminds clinicians to record this to prevent dosing errors. The service implemented a protocol to follow up secondary‑care prescriptions and add the correct dosing day to EMIS. Clinical searches identified that patients prescribed hydroxychloroquine had not consistently received recommended annual eye checks. This highlighted the gaps in the service’s assurance processes to flag where monitoring requirements under shared care arrangements were not being carried out in line with national prescribing guidance. Patients on hydroxychloroquine for over five years should have retinal screening due to the risk of retinal damage. Leaders told us they would run a search of these patients to ensure screening was arranged.
• Clinical searches identified 15 patients with a potential missed diagnosis of diabetes. Of the 5 records we reviewed, 4 showed coding or review issues, including delays in follow‑up blood tests after results in the diabetic range. One patient was coded as uncontrolled type 2 diabetes, while four were coded as suspected diabetes, a term not recognised for QOF or Ardens searches. There was no record these 4 patients had been informed of their results or referred for eye screening. Following our inspection, leaders updated coding and invited the affected patients for review.
• We asked the service to review all these patients.

We reviewed clinical records for patients who had been prescribed medicines which required monitoring. Our review showed that regular medicines reviews were completed to ensure medicines were safe and appropriate to patients needs.

The service had an established process to monitor high risk drugs (HRD). for patients in the community and residential care homes We saw a comprehensive HRD monitoring spreadsheet to support call and recall and which was maintained by the practice pharmacist team.

There was a programme of regular clinical audits of prescribing that focused on improving care and treatment. For example, the service had shared learning from a 3-cycle audit of diabetes patients at high risk of cardiovascular disease being offered SGLT2i therapy, in line with NICE guidance.

Prescribing data reviewed as part of our assessment confirmed the number of antimicrobials issued by the provider was lower than local and national averages.

Medicines and emergency medicines were stored, administered, and recorded securely, and staff managed prescription stationery appropriately. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments.