Caskgate Street Surgery

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

Safeguarding systems, processes and practices had been improved and implemented. Staff had received safeguarding training relevant to their role and understood how to report concerns. Recruitment processes were in place but we found not all appropriate recruitment checks had been completed. Safe staffing levels were in place and the provider had recently recruited new clinical staff into the practice. Staff training was appropriate and up to date and staff had received induction, annual appraisal and clinical supervision. However, there were limited documented formal supervision processes in place. Most safe systems, pathways and transitions were in place. There was a documented approach to the management of test results but it was not always clear when test results had been reviewed Most systems for the safe management of medicines, emergency medicines and equipment and medicines optimisation were in place. However, some processes required review. For example, appropriate and timely monitoring of some patients prescribed high risk medicines. An emergency drug held by the practice was not the appropriate strength. We observed medicines alerts were being actioned appropriately although in respect of one alert we found that risks had either not been discussed with the patient or not clearly documented. Monitoring of the cold chain was not carried out on a daily basis. There was a positive learning culture. Staff knew how to identify and report concerns, safety incidents and near misses. The practice learned and made improvements when things

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The limited feedback we received from patients prior to the inspection did not reflect any views on the learning culture.

Leaders told us they used incidents and complaints to improve systems and processes. Staff understood their duty to raise concerns and report incidents and told us these were discussed in some practice meetings to share learning. Staff and leaders were able to share examples of incidents and complaints, learning and improvement. Staff told us they felt able to raise concerns when things went wrong.

The practice had a significant event policy and complaints policy which was accessible to all staff members. The practice discussed events and incidents during team meetings and learning was shared with staff. Clinical issues were regularly discussed between members of the team including those not directly employed by the practice. The practice had a duty of candour policy and involved people when managing significant events. The practice had a clear system in place to record and investigate complaints. From the sample of complaint records we reviewed, we found the practice responded to peoples’ complaints in a timely and appropriate manner. The practice offered apologies to people when appropriate, lessons were learnt from individual concerns and complaints and action was taken as a result to improve the quality of care. Information on how to make a complaint was available both in the practice and on the practice website.

The limited feedback we received from patients prior to the inspection did not reflect any views on safe systems, pathways and transitions.

Staff told us they attended regular multidisciplinary team meetings where patients who may be vulnerable or those receiving end of life care were discussed and actions agreed and put in place.

We did not receive any concerns from commissioners or other system partners about delayed referrals or safe systems of care.

The provider had appropriate processes in place for referral to secondary care and specialist services. There was cover in place when staff who carried out this role were absent. There were clear processes in place for taking action when the practice received letters or discharge summaries from the hospital. Any actions required from these were forwarded to the appropriate person to take action. We saw that these actions were managed in a timely manner. Referrals to specialist services were documented, contained the required information and there was a system to monitor delays in referrals. There were systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment. There was a documented approach to the management of test results, and this was managed in a timely manner. However, we found that it was not always clear when test results had been reviewed as the patient clinical record system had not been updated appropriately by a clinician. During this assessment we found that new systems and processes had been introduced and these ensured that there were no longer backlogs of patient records requiring summarisation and incoming correspondence.

The limited feedback we received from patients prior to the inspection did not reflect any views on safeguarding people for abuse and improper treatment.

Staff we spoke with understood the process of how to report concerns and their responsibility to action appropriately. Leaders we spoke with told us that they had improved the systems and processes in place for safeguarding patients from abuse and improper treatment.

We did not receive any concerns from commissioners or other system partners about safeguarding systems and processes.

The practice safeguarding policy included appropriate legislation and guidance for safeguarding adults and children and young people. The policy covered the recommended aspects of safeguarding. Staff told us and we saw evidence that they had received training in safeguarding children to the appropriate level for their role in line with the Safeguarding Children intercollegiate guidance. Staff had received adult safeguarding training. They knew who the safeguarding lead in the practice was and how to raise concerns. We saw evidence of regular multi-disciplinary meetings which involved both internal and external stakeholders where appropriate discussion, actions identified and follow up was included. Safeguarding registers were in place, the lead GP told us reconciliation of information with the local authority to check accuracy had not occurred recently due to issues with the change over to a new patient clinical record system in December 2023. During our review of patient clinical records, we saw patients and family members had appropriate safeguarding alerts on their records to highlight concerns. Following the change to the new patient clinical record system safeguarding information, including alerts was not visible to all staff employed at the practice, this meant staff were not always aware that patients were at risk to allow appropriate action to be taken to provide safe care. This was rectified by the provider to ensure all staff had the appropriate viewing rights.

The evidence we reviewed did not show any concerns about people’s experience regarding involving people to manage risks at this practice.

Staff told us that people are informed about any risks and how to keep themselves safe through their treatment of conditions. Leaders told us of ways that they review consultations to ensure risks were managed whilst respecting patient choice.

At this assessment we found that the systems in place for the safe management of emergency medicines required strengthening.. Appropriate emergency equipment and emergency medicines were held with the exception that Adrenaline, held for the treatment of anaphylaxis was 10 times weaker than the required strength stated in national guidance. Following our assessment, the practice told us their processes had been amended to ensure the correct strength of adrenaline was stocked. The practice discussed cases in meetings to share risk and lessons learned.

Staff told us they felt safe to work at the practice, they told us facilities, equipment and technology were well-maintained so they could work safely and deliver a good quality of care to their patients.

We found no concerns regarding the equipment within the practice.

We found risk assessments were completed, most remedial actions were completed and the practice met the population needs.

The limited feedback we received from patients prior to the inspection did not reflect any views on safe and effective staffing.

Staff told us they received regular appraisals, they felt supported and that their development and training was discussed in the appraisal. Staff told us they attended regular team meetings but not all felt they were kept up to date with changes within the practice. Leaders told us they had recently recruited to clinical roles and this had increased the diversity of skills in the nursing team. A new GP had also been employed and was keen to work with the provider to make further improvements.

The provider had appropriate recruitment processes in place. However, we reviewed 5 personnel files during the site visit and found that whilst recruitment checks such as disclosure and barring (DBS) checks had taken place, 3 of the staff files did not contain references, induction and staff immunisation information. We reviewed the training records and found staff had received and were up to date with mandatory training and training required for their role. Clinical staff had easy access to informal clinical supervision. However, there were limited documented formal clinical supervision processes in place. Processes were in place for performance monitoring of prescribing practices of non-medical prescribers or Additional Roles Reimbursement Scheme (ARRS) roles to ensure correct prescribing practices.

The limited feedback we received from patients prior to the inspection did not reflect any views regarding infection prevention and control at this practice.

Leaders told us that their infection control audit had identified some issues, however they were unable to action these as they were awaiting new premises.

On the day of inspection, we found the practice to be visibly clean and suitable personal protective equipment throughout the practice. We found posters around the practice including, sharps injury, handwashing and clinical waste to support good practice.

The practice had clear roles and responsibilities and staff were aware of these and the practice kept up to date with new risks to infection control which was shared with all staff.

The limited feedback we received from patients prior to the inspection did not reflect any views regarding medicines optimisation.

Staff and leaders told us they had systems and processes in place to support the safe prescribing of medicines. The practice were supported by a clinical pharmacist and technician through the Additional Roles Reimbursement Scheme. Prescribing and medicines management were discussed at clinical meetings.

During our checks we found all medicines were stored securely in the practice and checked regularly. Appropriate emergency equipment and emergency medicines were held with the exception that Adrenaline, held for the treatment of anaphylaxis was 10 times weaker than the required strength stated in national guidance. Following our assessment, the practice told us their processes had been amended to ensure the correct strength of adrenaline was stocked. Vaccines were ordered and stored in accordance with national guidelines and the practice had systems in place to monitor the temperature of vaccine fridges. However, monitoring was not carried out daily in line with the practice policy. We reviewed the monthly checklists and found that when one staff member was absent from work the temperatures of the vaccine refrigerators were not checked. Following our assessment, the practice told us they had updated their processes to ensure the temperatures were checked daily. The practice had effective systems in place for the safe and effective management of clinical correspondence. The practice had up-to-date Patient Group Directions (PGDs) in place for nurses carrying out specific vaccinations.

At our inspection in May 2023 under the previous registration we found that there was an ineffective system in place for undertaking medicines reviews. We found issues with the process for monitoring patients’ health in relation to the use of medicines including medicines that require monitoring (for example, warfarin, methotrexate and lithium). Patients were not always having the blood tests required to ensure they were safe to continue taking their prescribed medicines. At this assessment we found that new systems and processes were in place to ensure effective medicines reviews were undertaken for patients on repeat medicines. However, we found that some patients were still not having the required blood tests to ensure they were safe to continue taking their prescribed medicines. The practice had a policy in place for the management of medicines including repeat prescribing. The practice had systems in place to monitor the appropriateness of non-medical prescribers and clinical supervision was in place although we found a lack of documented clinical supervision. Our review of patient records demonstrated that further monitoring was needed to ensure patients who had been prescribed 2 or more doses of steroids were followed up within a timely manner.

At our inspection in May 2023 under the previous registration we found that there was an ineffective system in place for undertaking medicines reviews and with the process for monitoring patients’ health in relation to the use of medicines including medicines that require monitoring (for example, warfarin, methotrexate and lithium). At this assessment we found that new systems and processes were in place to ensure effective medicines reviews were undertaken for patients on repeat medicines. However, we reviewed a selection of patients records and found concerns. Patients were not always having the blood tests required to ensure they were safe to continue taking their prescribed medicines . We identified that some patients prescribed Direct Oral Anti-Coagulant medicines did not have a creatinine clearance recorded in their patient record which is necessary to ensure the correct dose is being safely prescribed. We also identified one patient who was being prescribed an incorrect dose based on the information available in the patient record. Monitoring was overdue and this had not been identified at the last medicines review. During the searches undertaken as part of the remote assessment we looked at an historic medicines safety alert. From our review of 4 patients identified in this search we found that the risks associated with taking the combination of medicines specified in the alert had either not been discussed with the patient or not clearly documented. The practice assured us that these patients had been reviewed and new processes implemented to ensure this was not an issue going forward.