The Hollies 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 reviewed 4 quality statements in the Safe key question, this included Learning Culture, Safeguarding, Safe and Effective Staffing and Medicines Optimisation. The scores for the other quality statements are based on the previous rating for this key question. We found there was some culture of safety and learning through the investigation of complaints and incidents however these required strengthening. Risks were not routinely reviewed or discussed to ensure practice wide learning and improvement. The process in place for the management of medicines and monitoring of patients prescribed high risk medicines required improving. There was a lack of effective oversight of staff training. Safeguarding systems required strengthening.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The information we reviewed and the patients we spoke with demonstrated people had opportunities to provide feedback and were aware of how to make a complaint. We saw complaint information was available at the practice as well as on the practice website. The practice received 9 complaints in the previous 12 months. Although the complaints reviewed during the inspection did not appropriately signpost the individual to the Parliamentary Health Service Ombudsman, overall we found complaints had been dealt with in a timely manner.

The leadership team were aware of the challenges the practice faced during the absence of senior leaders. They were aware of challenges to ensure consistent staffing arrangements were in place and the effect this had on the performance of the practice. They were assured that patient safety was not at risk but accepted improvements needed to be made in the risk management processes. Feedback from the Integrated Care Board displayed that the practice was working with them to access support that was required, the practice was accessible and responsive. Staff we spoke with informed us that the months prior to the assessment were difficult and it was not clear who held position of responsibility due to the high turnover and frequent changes of staff in lead roles. The leadership team were unaware of all the challenges the practice was experiencing. We were unable to ascertain that learning from complaints and incidents was routinely shared or that staff were able to raise concerns in a supportive environment as we only had access to staff meeting minutes held in March and April 2024. We also identified that meetings held in these months discussed significant events that were not consistent with evidence shared with CQC as part of this assessment.

The practice had a complaints policy in place and information was accessible to patients. There was a system to record and investigate complaints in a timely manner. Patients received a final response, however, from the complaints reviewed, the practice did not always include details of the Parliamentary Health Service Ombudsman for people who wanted to escalate their complaint further. The practice had an incident reporting procedure and form but we did not see evidence of a significant events policy. There had been 7 significant events reported in the last 12 months. The incidents we reviewed reflected that the practice followed their duty of candour policy to involve and inform people when errors occurred. We saw the practice had investigated the cause of incidents to identify areas for improvement. Appropriate action was taken following any learning identified, for example the practice recalled 23 patients as part of an audit to be followed up and reviewed appropriately. We found significant events were not always signed by a responsible person to confirm that all outstanding action had been completed or when the next review was taking place to ensure learning was embedded as part of the practices risk management. The practice had effective systems and processes in place to manage and respond to safety alerts. During the clinical patient searches undertaken as part of the remote inspection, we reviewed 1 safety alert. We reviewed 5 of the 39 people prescribed a Teratogenic drug and found appropriate advice had been given on the risks of these medications.

Feedback via staff interviews and staff questionnaires displayed that staff understood safeguarding and were aware of who the safeguarding lead was. Staff stated they had received safeguarding training appropriate to their role however this was not always reflected in the training records we reviewed. Leaders told us that a safeguarding clinic was held on a weekly basis where all cases were discussed, we asked for the minutes of these meetings but the practice did not provide them to us. A member of nursing staff we spoke with informed us of monthly multidisciplinary meetings which were taking place but that a meeting had not been held in the 3 months prior to the assessment. We were informed the practice did not have a system to follow up children who attended Accident and Emergency, the lead GP informed us a protocol would be created for this.

We attended meetings with external stakeholders, prior to the assessment. Improvements to safeguarding systems were suggested and the practice had agreed to implement these changes.

At the previous inspection in July 2023, we found that safeguarding was monitored, training certificates of staff and a training matrix with oversight of staff training and levels was in place and up to date. At this inspection, we found the practice did not have safeguarding policies that highlighted training in line with the intercollegiate guidance required for staff working at the practice. We were not assured all staff had adult and children safeguarding training that was appropriate for their role as the training matrix provided did not have oversight of all permanent and locum staff with the appropriate level of adult and children safeguarding training. The practice did not have an effective system to identify vulnerable patients or their family members for example we did not see an updated record of children and adult safeguarding registers. Whilst we were informed that weekly safeguarding clinics were being held, we were not provided with any minutes of these meetings.

During our onsite inspection, we spoke with people who were using the service. Feedback regarding clinical and non-clinical staff was positive. We did not receive any feedback through other sources.

Leaders were aware of the staffing challenges and the impact this had on the performance of the practice. They felt there was now an adequate number of clinical staff to meet the needs of patients which included 4 full-time salaried GPs who were complemented by a range of staff from the Primary Care Network including 2 Advanced Nurse Practitioners and a Pharmacist. The new management team felt the practice would benefit with more full-time staff. They had plans to conduct a training analysis as they felt the skills mix of staff was not currently adequate. The practice manager informed us a health care assistant was recently recruited to provide phlebotomy clinics at the practice to improve medicines management and the monitoring of patients prescribed high risk medicines. Leaders gave us some examples of how staff were given opportunities for learning. These included clinical staff being given opportunities to conduct clinical audits, a pharmacist undertaking training at the practice and the opportunity to attend training sessions with other local practices. We were informed that staff who were not directly employed by the practice were managed through multidisciplinary meetings or feedback, we did not see any minutes of these meetings. Some staff we spoke with told us that the months prior to the assessment had been difficult due to the high turnover of staff. Some staff felt unsure who the leads were as the roles changed frequently. A staff member we spoke with informed us they did not have protected time for learning since the previous long term practice manager had left the practice. Overall, staff felt there was good peer support amongst colleagues however most staff felt there was a lack of senior support.

We were provided with a staff list of permanent and locum staff which had not been updated to include the salaried GP staff of whom we were informed worked at the practice. The staff list showed there was a reception and administrative team who were supported by the practice manager, assistant practice manager and business manager. There was a clinical team of 3 nurses and 2 health care assistants supported by several locum GP’s and the lead GP. One of the Health Care assistants had recently been recruited and was provided with an induction prior to commencing the role. We found that processes for supervision and oversight needed reviewing. The staff training matrix displayed several gaps in required training, some staff were also overdue mandatory training. We reviewed 4 staff files and found DBS checks had been completed in line with the practice procedures. Staff immunisations were recorded and in cases where information was awaited from the staff member’s GP practice, this was noted and monitored.

During our onsite assessment, we spoke with people who were using the service. Feedback regarding medicines management and monitoring was positive. Our remote clinical searches displayed monitoring and reviewing of patients prescribed high risk medicines required strengthening.

The lead GP was aware of the gaps in medicines monitoring and reviews and informed us a plan of action had been drafted. They were in the process of reviewing the systems and processes to support the safe prescribing of medicines. The practice worked closely with the clinical pharmacist from the Primary Care Network and also recruited a member of staff to provide Phlebotomy clinics at the practice. Leaders and staff informed us they managed non-medical prescribers by using the clinician handbook, including formulary. They monitored the clinical system that was used in the practice and stated they were available for advice and guidance.

Emergency medicines, vaccines and medical equipment had been reviewed and were appropriately stored with clear monitoring processes in place. There were appropriate arrangements in place for the management of vaccines and for maintaining the cold chain. We saw fridge temperatures were routinely monitored and the vaccines we reviewed at random were in date and stored appropriately. The practice held appropriate emergency equipment and emergency medicines which were checked on a regular basis. Patient Group Directives and Patient Specific Directives were in place, we reviewed 2 of each and found they had been signed by staff and the authorising lead in line with national guidance. Prescriptions were stored securely, and a record of serial numbers was maintained.

Overall, we found the practice had ineffective systems for the appropriate and safe use of medicines, including medicines optimisation. Our review of clinical records displayed there was inconsistent clinical oversight and overall monitoring of patient care. The practice was unable to demonstrate the process in place to ensure the prescribing competence of non-medical prescribers through evidence of reviews of their prescribing practice being supported by clinical supervision, peer review, audits or protected time for case review.

During this assessment, we carried out remote clinical searches of patient records and found concerns in the monitoring of people prescribed high-risk medicines. We reviewed patient’s prescribed a medicine (Methotrexate) to treat rheumatoid arthritis which requires regular blood monitoring due to the risk of side effects. We found 32 out of the 85 patient’s prescribed this medicine did not have the required monitoring in the last 6 months. We looked at people prescribed a medicine (Lithium) used as a mood stabiliser in patients with bipolar disorder or severe depression which requires regular blood monitoring. We found 6 out of the 8 patient’s prescribed this medicine did not have the recommended monitoring. A search on missed diagnoses of diabetes identified 10 people. We reviewed 5 patient records and found 3 out of the 5 patient’s had not been coded appropriately and 2 of these had no monitoring. We also identified structured medicines reviews were not always comprehensive. We reviewed 5 medication reviews and found 3 of the 5 reviews only commented on 1 or 2 of the medicines that were prescribed. We looked at patient’s prescribed a medicine (Gabapentinoids) to treat neuropathic pain and occasionally epilepsy. We noted that discussion about the medicine in question was not always documented in the reviews. Our clinical searches reviewed some patient’s with specific long term health conditions. We reviewed 5 records of patient’s who had diabetes and noted only 1 patient had a diabetic annual review in the last 12 months. Overall, we found there was regular management and reviews of patient’s with asthma, hypothyroidism and chronic kidney disease stages 4 or 5.