East Shore Partnership

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 assessed and inspected against five quality statements, Learning culture; Safeguarding; Safe environments, Safe and effective staffing and Infection prevention and control. During our assessment of this key question, we found people were not always protected from harm in relation to the premises, including the management and safety of the hot water systems and the risk of exposure to legionella. The practice did not maintain a suitable record of staff immunisations to ensure people were kept safe from the risk of infection and to reduce their exposure to infectious diseases. The above evidence resulted in a breach of regulation 12 Safe care and treatment, of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The practice had intermittent hot water issues since November 2023 although it was not possible to verify an exact date due to a lack of records maintained by the practice in relation to the incident. Whilst awaiting to resolve the hot water issues, the practice had installed under sink heaters in clinical areas. There was a lack of monitoring and oversight in relation to staff appraisals, staff induction (including preparation of staff induction packs) and nursing clinical competencies. This included clinical supervision and monitoring of non-medical prescribing to ensure that non-medical prescribers were not prescribing outside of their competency. This was a breach in regulation 18 Staffing, of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Feedback from people who used the service was positive, including feedback from the Patient Participation Group (PPG). The shortfalls we identified in relation to the premises and environment could impact people’s experience.

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.

Leaders told us that clinical issues were regularly discussed between members of the team at practice meetings. GP partners told us they were responsible for investigating incidents which required clinical review. Staff we spoke with told us there was a no blame culture and staff felt able and told us they were encouraged to raise concerns. Staff were aware the learning that had taken place following the review of safety incidents and the changes that were needed to improve care for people. However, leaders told us they had not recorded a risk assessment or raised an incident investigation in relation to the hot water system failing at the practice to demonstrate the impact it had on services and people. Leaders could not comprehensively explain what actions they had taken to identify and mitigate any risk this posed to people, who was responsible for implementing any remedial actions to the failure or any learning that arose to prevent the issue reoccurring.

We identified that the practice had recorded 45 complaints and 11 incidents as significant events in the last 12 months. We reviewed the practice’s complaints management processes and found that complaints and concerns had been appropriately investigated. People received responses to incidents in a timely manner and in line with the duty of candour. Meetings were held regularly where significant events were discussed for a wider learning. Learning outcomes were recorded on the action log and shared with staff through practice meeting minutes.

People told us that they had opportunities to provide feedback and they knew how to make a complaint. We spoke with two members of the Patient Participation Group. Both told us they had positive engagement with the practice and felt that the practice wanted to learn and was proactively asking for feedback.

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.

The practice had a safeguarding policy with a safeguarding lead. Systems were in place to appropriately refer people to local authorities safeguarding teams and information was shared amongst community teams where required. We found that staff training requirements were not set out within the adult safeguarding policy. Although this was stated within the children’s safeguarding policy, the training requirements were not in line with national safeguarding guidance. Not all staff had completed the appropriate level safeguarding training in line with national guidance. There was a lack of oversight to ensure staff complied with training and that staff had the knowledge and skills to protect people from potential harm. For example, we found that not all clinical staff had completed safeguarding children and vulnerable adults level 3 training and this had not been identified by the practice prior to our assessment. A mixture of clinical and non-clinical staff members had chaperone responsibilities as part of their role. Those staff members had completed Disclosure and Barring Service (DBS) records in place.

Staff told us there was a safeguarding register and that vulnerable people who used the service were discussed in clinical meetings. Staff were able to identify local arrangements for raising safeguarding concerns. Leaders told us senior staff discussed safeguarding concerns at regular clinical governance meetings, this included information shared by Health Visitors in relation to children of concern. Staff told us they reported concerns with the local authority where required.

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 we spoke with could not tell us whether the 25 remedial actions identified by a fire risk assessment completed in February 2021 had been completed. These staff members were unaware whether any further fire risk assessments had been carried out since 2021 to ensure fire prevention arrangements remained appropriate. Staff told us there were a lack of risk assessments in place to address any of the environmental risks at the premises identified during this assessment. This included a lack of risk assessments in relation to the broken window and carpet that had been identified as a hazard and that control measures had not been implemented to ensure people remained safe. Leaders told us that risk assessments had been completed in relation to staff health and safety, which we were able to confirm such as ‘working from home’, ‘staff pregnancy’ and ‘COVID-19’. Leaders also told us the practice carried out Portable Appliance Testing (PAT) every four years to ensure electrical appliances and equipment remained safe to use.

Safety related policies and procedures had not been reviewed effectively to ensure up to date information in line with national guidance was available for staff to work to. Some of these policies had not been reviewed within the dates set out by the practice. For example, the Health and Safety policy was due for renewal in September 2021, but had not been reviewed to ensure it continued to reflect current best practice guidelines. The policy was brief and did not refer to key requirements to ensure devices remained safe to use. For example, the policy did not refer to Portable Appliance Testing (PAT) or equipment calibration. We identified that PAT testing of electrical items had not been carried out since 2020. A policy was not available to show what levels of maintenance was needed according to the risk of an electrical item becoming faulty. The provider could not determine whether the current frequency of PAT was appropriate for all items. We requested documentation in relation to equipment calibration but could not be assured that all devices had been calibrated as per the manufacturers’ guidelines. We were provided with evidence of 2 pieces of equipment that had been calibrated in the last 12 months. Actions had not been taken to ensure people were protected from the risk of fire. The practice had a fire risk assessment dated February 2021 carried out by an external contractor, which included 25 actions which needed to be undertaken to ensure fire safety. These included replacement of damaged doors, door handles, replacement of emergency lighting and cold smoke seals. None of these actions had been recorded as completed. The practice recorded health and safety related testing requirements through a facilities and premises log. We identified areas for retesting had not been carried out such as emergency annual light testing. We noted that a recent fire drill had taken place in March 2024, prior to this date, there were no records in place.

We saw elements of the environment could pose risks to people. During our on-site visit, we observed there was a notice on a window saying, 'Do not open’ due to the window being broken. The window was open later during the on-site visit despite the warning notices. We observed the carpet in reception appeared damaged held together with tape creating a tripping hazard. Leaders told us that this was a remnant of COVID-19 spacing markers as tape had used to ensure appropriate distance maintained and had not been removed.

Recruitment and Human Resource (HR) records were not always kept in-line with practice policy. We carried out a review of the provider’s recruitment checks in relation to 4 members of staff and found systems and processes were ineffective to ensure that information was available and up to date for persons employed in line with practice policy. We identified there were no records kept for clinical staff in relation to immunisations required to safely carry out their roles and to ensure people were kept safe from the risk of infection by reducing their exposure to infectious diseases. At the time of assessment, we identified an ineffective system for managing staff appraisals and reviewing clinical competencies. The schedule of appraisals had been sent to staff but we found planned appraisals had not always been completed. Records were unclear around what competencies were held by nurses employed at the practice, as well as how they were kept up to date to ensure these staff members were suitably skilled and trained to carry out particular care and treatment. The practice had an electronic training system in place until November 2023 when this system was decommissioned. The system was not replaced until March 2024 leaving a period of 3 months without monitoring and managing staff training compliance to ensure staff had up to date knowledge and skills to undertake their roles. The training records provided showed non-compliance in all areas of required training. We identified a lack of regular, documented clinical supervision for non-medical prescribers, instigated by their supervisor. This meant non-medical prescribers might not always receive the support they needed to ensure they continued to only prescribe medicines they were competent to prescribe.

People could feed back their experience of the service via NHS UK, formerly known as NHS Choices. Feedback data showed a total of 206 reviews, 41 reviews since the start of 2024, with an average rating of 4.2 star out of 5. We identified examples of positive feedback relating to staff such as clinicians listened to people and provided good quality care and treatment. Administrative staff were described as professional and friendly. The practice’s national GP patients survey results from 2023 showed that people felt they were treated with care, were listened to and had confidence with staff in line with local and national averages, including staff's understanding of meeting mental health needs.

The remit for the lead nurse role was unclear and required revising. The job specification described a clinical lead who provided clinical leadership, mentoring and had responsibilities as the infection control lead. Leaders told us the lead nurse role was a management role only, providing human resource and operational leadership for the nursing team and all nurses reported to GPs for any clinical matters. This did not align with the job specification or other staff understanding of the role. This posed a risk to ensure staff were clear and understood their roles and responsibilities to meet the needs of people using the service. Staff we spoke to said they could discuss clinical queries in relation to their prescribing or care and treatment planning with leaders who had an ‘open door’ policy. They were not aware of any formal processes to monitor their performance, including prescribing for non-medical prescribers to ensure people were prescribed medicines that were safe and in line with national evidence-based guidelines. Leaders told us that rotas were planned 6-8 weeks ahead of time and administration staff were managed effectively to ensure patient demand was met at both practice sites. Leaders told us that three new GPs had been recruited and due to start in April and May 2024. This would help to assist with more appointments to meet the on the day and acute demand. This will also give GP partners more time to support staff supervisions and improve oversight of ongoing and routine care for people with long-term conditions. Two staff members told us they carried out chaperoning but had not completed chaperoning training. We were unable to verify this due to the practice training systems being merged. We were provided with data which included information about staff training, which was difficult to interpret to determine the overall training compliance of staff.

The practice had not documented a risk assessment or significant event investigation in relation to the hot water system failing. It was therefore not clear when and what actions had been taken to identify and mitigate any risk this posed to people and who was responsible for the remedial action and safety monitoring. The practice had installed immersion heaters into some clinical rooms as temporary actions. The practice had failed to assess and record the risk to people of receiving treatment with water which was not at a safe temperature. There was a risk of scalding to service users who undertook ear irrigation procedures in the absence of a risk assessment. The practice developed a Safe Water Policy in March 2024 which included a template for a risk assessment in relation to the risk of legionella bacteria growth. However, the legionella risk assessments were incomplete and the practice had not put effective control measures in place to reduce the risks related to legionella bacteria. The practice water temperature testing records showed in some rooms the water temperature was outside of the safe temperature range, increasing the likelihood for legionella to grow. No action had been taken between January and February 2024 to adjust water temperatures to prevent the risk of legionella infection. We saw evidence that a legionella test had been carried out in November 2023 but despite the continued hot water issues, there had been no further legionella testing since that date or a risk assessment indicating why further testing would not be required. The practice could not provide evidence of internal IPC audits, an annual IPC statement, regular hand washing audits, cleaning records or audits in relation to clinical waste.

Staff we interviewed in relation to the ineffective hot water system were either vague about dates, or they recalled various dates which were not consistent with each other. Due to the inconsistent feedback from staff regarding the ineffective hot water system and a lack of records to document the incident, leaders could not show how they had considered the risk to service provision and to people. This led to delays in remedial actions being taken to rectify the issue. Staff we spoke to were not always clear about the risks that the hot water system posed to people or the environment in relation to legionella. Staff told us the practice had boiled water in order to carry out procedures such as ear irrigation during the interim period of the ineffective system. Leaders told us this type of treatment had ceased at the end of 2023. The Infection Prevention and Control (IPC) lead told us that the practice carried out cleaning checks of clinical rooms, including equipment, however, they could not provide documentation to support this.

We could not collect sufficient evidence to score this evidence category. Information in relation to people's experience of infection prevention and control (IPC) was not covered within the National GP Patient Survey. Information was not available relating to this evidence category through NHSE feedback or via Friends and Family Test (FFT) data.

During our on-site visit, we observed that the practice did not have an effective hot water system in place. The practice had not had hot water since November 2023 although it was not possible to verify an exact date as there was no documentation in relation to the hot water failure. We observed that two clinical rooms, the kitchen, patient and staff toilets did not have a supply of hot water. Ensuring an adequate, reliable hot water supply is key to creating comfortable conditions for people and for maintaining a hygienic environment. We observed that improvements to the cleaning of the premises was required. For example, some rooms had debris on floors despite being told that the cleaner carried out checks routinely.

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