168 Medical Group

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

Staff promoted a culture of safety and the team learned from incidents and near misses. The team managed risk collaboratively with multidisciplinary colleagues and had established networks that worked to protect patients with complex needs. Staff supported patients to make decisions that included the risks of some lifestyle choices with each individual’s right to be independent. The senior team made sure there were enough skilled and trained people to deliver safe care. However, some areas of medicines optimisation did not reflect good practice. For example, there were gaps in the completion of some documentation and senior staff did not have consistent oversight of junior colleagues responsible for stock. The senior leadership team provided evidence of immediate improvements they had made in response to our assessment findings, including to the medicines governance system

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.

Patients told us they felt safe and cared for by staff and this was reflected in online feedback to the practice. Staff demonstrated how they contacted patients in the event of an error or concern as part of a culture of openness and honesty.

Staff worked in a culture that promoted learning and improvement. Staff reported significant events were reported using the practice’s electronic system. Significant events were reviewed by multidisciplinary colleagues to identify causes and opportunities for learning. The senior team supported staff in reflective practice and worked with other teams involved in patient care to improve processes. For example, the practice streamlined care pathways and working relationships with community partners after a patient came to harm because of an ‘admission avoidance’ incident. Admission avoidance is a process used by providers to reduce the number of patients admitted to hospital by providing community-based care instead. Staff said they worked within a no blame culture that promoted learning. Staff reported incidents or errors and worked together to identify resources or training needed to avoid recurrence. The practice had introduced a Freedom to Speak Up Guardian role. They were a point of contact for any member of staff to raise concerns about colleagues, the practice, or leadership, without fear of retribution. Two GPs were undertaking fellowships in the primary care network, 1 focused on improving supervision and the other on promoting mental health wellbeing amongst staff. Fellowships are roles funded to help improve specialist training and care provision. This was an example of the focus the senior team placed on learning and development opportunities outside of the immediate practice. Staff understood the duty of candour policy and when to implement it in consultation with the senior team. Staff discussed learning from previous incident investigations and how this influenced the care they delivered. This included recent changes to safeguarding protocols and prescribing for pregnant patients with known cardiac conditions.

The practice had policies and procedures to identify and learn from near misses and incidents. This included a system to act on central alerting system (CAS) information and alerts issued by the Medicines and Healthcare products Regulatory Agency (MHRA). These systems provide healthcare staff with updates on medicines safety identified from research or incident reports elsewhere. Staff responded to safety alerts consistently. The practice had clear processes to support GPs providing care through alternative arrangements such as locum GPs and remote GPs. Remote GPs assessed patients through a digital channel and referred them to GP colleagues in the practice for examinations and diagnostics. This was a safety mechanism to provide capacity for urgent referrals where a patient needed an assessment in person.

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.

Safeguarding was embedded across all aspects of care planning and delivery and the practice used a multi-agency safeguarding policy to guide care and decision-making. Staff considered the needs of vulnerable patients and those with complex needs. The team used weekly clinical meetings to review the needs of patients receiving palliative care and those who were living with frailty, and those with social care needs. The practice had a policy and process to manage suspected or disclosed cases of female genital mutilation (FGM). This reflected national guidance and included referral details to specialist organisations where staff found children were at risk. Staff demonstrated a consistent understanding of the safeguarding risks some people faced at home in their relationships or through their living circumstances. Staff knew who to contact in the event of an urgent safeguarding situation or crisis and maintained up to date links with specialist services. For example, the team had worked with a sexual assault centre to provide urgent care for a patient in need and had developed links with an agency equipped to support women subject to religious honour-based abuse. The team used effective processes to support vulnerable and at-risk patients who did not want help or who rejected interventions. They worked collaboratively with the local authority safeguarding team and mental health teams to solve key problems. Where patients were close to the end of life and had vulnerabilities, staff worked with colleagues in the wider health system to provide individualised care.

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.

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

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.

During our site visit, we found a number of areas for improvement. Nurses used patient group directions (PGDs) to administer medicines. PGDs provide a legal framework that allows some registered health professionals to supply and/or administer a specified medicine(s) to a pre-defined group of patients, without them having to see a prescriber. We found staff had not correctly completed PGDs and there were gaps in signatures, auditing, and compliance with national standards. After our site visit the provider sent us evidence of immediate improvements, including a new governance process to monitor standards and a completed review of all PGD authorisations. Staff knowledge of emergency equipment held at the main practice and satellite site was inconsistent. For example, their understanding of the location and stock of nebulisers was inaccurate, and some clinical staff were unaware of the presence of vaccines on site. Other areas of practice met good practice standards, such as adherence to the cold chain of medicines storage. The cold chain means that medicines are stored at consistent temperature in line with manufacturer guidance. After our assessment the provider sent us evidence of immediate changes and improvement, including policies, staff training, and leadership oversight. Staff maintained safe systems for the storage and administration of medicine, including a digital temperature checking system and cold chain auditing. Both systems meant patients were assured of medicines safety because staff had suitable systems in place to comply with manufacturer guidance. The practice pharmacy team maintained oversight of such systems and implemented improvements whenever audit results or feedback identified such opportunities. Staff acted on MHRA alerts and reviewed patient care records to ensure prescriptions met updated guidance. Our checks of prescribing documents reflected consistently good practice.

Staff used a call and recall administrative process to encourage patients with long-term conditions to attend health and medicine reviews. The prescribing team carried out regular safety checks to ensure prescribing met national and local guidance. For example, the service had embedded National Institute for Health and Care Excellence (NICE) clinical knowledge summaries into local prescribing guidance and staff used these alongside the British National Formulary and British National Formulary for Children to benchmark standards. Staff attended weekly clinical meets to review the prescriptions and medicine plans of patients with complex or changing needs. The team had a clear focus on vulnerable patients and those at risk, such as frail patients with worsening overall health. Non-medical prescribers (NMPs) worked with GPs and the primary care network pharmacy lead to ensure practices were working in line with expected safe standards. An NMP is a healthcare professional other than a doctor who is trained to prescribe medicine. NMPs carried out peer reviews with each other and had access to advanced care practitioner training to develop their skills and competencies. A GP maintained oversight of NMP prescribing as part of a safety and auditing process. Policies and procedures relating to unusual prescribing protocol, controlled drugs, and prescribing errors were up to date and there was evidence of regular reviews.

We reviewed an anonymised sample of patient prescribing records to check for safe practices. In most cases we found GPs contacted patients for reviews at appropriate intervals when renewing prescriptions and when seeking blood tests or other diagnostics. However, in some cases the practice continued to prescribe long-term medicine without up-to-date blood results when patients did not respond to messages. For example, the practice did not always consistently review patients prescribed asthma inhalers on a frequent basis. We discussed this with the senior team who scheduled immediate reviews. Where MHRA alerts resulted in the need for changes in monitoring protocols, the senior team implemented an action plan. This included changes to patients over the age of 65 prescribed a certain type of antidepressant and female patients of childbearing age prescribed antiepileptics. The pharmacy team proactively reviewed patient records as part of updates to national guidance. The pharmacy team had 9 medicines optimisation audits and projects underway, 6 of which focused on quality and safety. Audits included a prescribing review for patients receiving treatment for acne, a menopause treatment review, and a review of medicine interactions to identify potential improvements in treatment.