Russell Street Group 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 assessed 8 quality statements from this key question. We found the practice did not have clear systems, practices and processes to keep people safeguarded from abuse, there were gaps in systems to assess, monitor and manage risks to patient safety, including systems for the appropriate and safe use of medicines and the practice did not have a system to learn and make improvements when things went wrong. As a result, we have identified a breach of Regulation 12: Safe care and treatment, of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

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.

People’s feedback in relation to the learning culture within the practice was limited. From the feedback we received, patients told us that they had opportunities to provide feedback and they knew how to make a complaint.

Leaders told us that safety incidents were investigated and recorded on a significant events log. However, our findings during this assessment indicated the recording and investigation of events and incidents was inconsistent. Staff we spoke to were not always clear when to raise a significant event. Through our conversations with leaders, it was clear they did not understand their duty to raise concerns and report safety incidents and near misses. This included when incidents required regulatory actions. For example, a notifiable incident from February 2024 that should have been reported to CQC, was not submitted until prompted in June 2024. Learning from safety incidents was not consistently shared with staff or discussed at meetings.

The system in place to learn and make improvements from significant events was not always effective. Whilst some incidents were reported and investigated, with evidence of duty of candour, this was inconsistent and not always the case. Learning from significant event was not consistently discussed at meetings or shared with all relevant staff members.

The patient and Patient Participation Group (PPG) members we spoke to and received feedback from told us their referral to secondary care was managed appropriately. A PPG is a group of patients, carers and GP practice staff who meet to discuss practice issues and patient experience to help improve the service. However, reviews on an external online review website showed some patients had raised concerns that referrals were not completed in a timely manner.

Staff and leaders told us there was a system to ensure referrals to specialist services were documented, contained the required information and there was a system to monitor urgent referrals and any delays. This was not reflected within our assessment findings as we identified a referral from November 2023 which required a resubmission but did not appear to have been completed. Leaders explained they had recently trained a member of staff to process information where patients moved between services.

Feedback from system partners was mixed and highlighted challenges in the provision of a collaborative, joined-up approach to managing patients care. For example, feedback from local pharmacies identified improvements were needed into how the practice shared information relating to prescriptions and medicines. However, the feedback from 2 local care homes was positive and shared there was a lead GP who provided continuity of care for the residents and told us the GPs were supportive and accommodating.

There were processes in place to manage patient pathways or transitions including referrals and sharing and receiving of information with external health services. However, it was unclear if these processes were followed as our clinical searches identified a lack of process and oversight over administrative tasks. For example, our searches found 5,113 tasks (including correspondence, referrals and other tasks) within the clinical system which dated back to October 2023. From our analysis it was unclear if these tasks and corresponding actions had been completed or closed and staff were unable to inform us.

Patient feedback regarding safeguarding systems was limited. However, patient feedback indicated patients were aware of the chaperone system and had been offered chaperones in appropriate circumstances.

Staff understood their safeguarding responsibilities, knew who the practice safeguarding lead was and knew what action to take if they thought a person was at risk of potential harm. Leaders told us the safeguarding lead attended local safeguarding meetings arranged by the Integrated Care Board (ICB), however, no meeting minutes could be provided and no updates from these meetings could be explained. In-house safeguarding meetings and discussions were infrequent and from our review of the in-house meeting minutes, safeguarding updates, concerns or actions were not discussed or shared with others.

We did not have any concerns on record or directly from stakeholders such as commissioners or the local authority regarding safeguarding at this GP practice.

Safeguarding systems, processes and practices related to safeguarding were not always operated effectively. The practice had a safeguarding lead in place; however, the practice was not able to provide assurances that the safeguarding registers for child and vulnerable adults within the clinical care record system were accurately completed and up to date. For example, the provider was not able to tell us how many patients were on the safeguarding register or when it was last reviewed and updated. However, following the assessment, the provider told us the safeguarding lead was now reviewing all the safeguarding registers and reviewing their records including care plans. The practice had safeguarding policies in place. However, the policy did not contain up to date national guidance or contain the correct local contact details to raise safeguarding concerns. There were processes in place to provide all staff with safeguarding training. We saw all staff had completed the appropriate level of children’s and adults safeguarding and prevent radicalisation training.

Reviews of patient feedback did not indicate any feedback regarding risk management.

Staff, specifically clinical staff described their work and steps taken to manage clinical risks and how they prioritised risk appropriately. Leaders told us how they were identifying, managing and mitigating risks, this included practice specific risks, national risks within primary care, and challenges within the patient demographics. However, our findings throughout the assessment indicated the processes to manage risk was not embedded.

Systems and processes related to risk management were not always operated effectively. There was little assurance that the practice assessed or managed risk appropriately and staff and leaders understood the risks. For example, following an incident made in February 2024 the practice did not take appropriate action to carry out a risk assessment to support staff and patients.

Staff told us they worked in a safe environment and the leaders had completed a variety of actions to ensure safety was maintained. Staff also described how the different sites presented different challenges to maintain a safe environment, identifying the differences between the converted house surgery (Russell Street Group Practice) and the 2 purpose-built health centres (Coley Park Surgery and Burghfield Health Centre).

During our site visit, we visited 2 of the 3 sites where services are provided from. We saw the environment was safe and well maintained. This included clinical equipment which was calibrated at regular intervals.

There were processes to manage the health and safety of staff, patients and visitors attending all 3 sites. Whilst most risk assessments had been completed and actions followed up, the provider could not provide any evidence of fire risk assessments or servicing of fire equipment. We have alerted the local fire service to our concerns regarding fire safety.

Patients and PPG members we spoke to and received feedback from provided mixed feedback about staffing levels. Some felt more GPs were required to improve appointment availability whilst others felt there was enough staff to meet patient needs. However, feedback also included they felt safe with staff and had received information about their health, care and support available.

Most staff told us they had the opportunity to undertake training related to their role. They also told us, whilst the practice and primary care had seen significant growth in the last few years, there were appropriate staffing levels and skill mix to make sure people receive consistently safe, good quality care that meets patients’ needs. During our discussions with leaders, it was unclear as to the roles of several members of staff. For example, a healthcare assistant had been incorrectly referred to as a nursing assistant and a medical summariser had been noted as a GP assistant. Leaders told us this was because those staff members were undertaking or due to undertake this training but could not provide evidence to demonstrate this. This aligned to errors on the practice website which provided inaccurate job titles. Leaders also told us a receptionist had been recently trained to summarise new patient notes and could therefore provide additional cover or support if required. However, the staff member had not been made aware of any training or these additional job role responsibilities.

We reviewed the recruitment files and process followed for 6 members of staff and found the practice had completed relevant and appropriate recruitment checks. This included the process to record staff vaccination and immunisations. However, the system to monitor and carry out DBS checks was not effective. For example, DBS checks were being carried out inconsistently and the recruitment policy was unclear on how often DBS checks should be renewed. Leaders told us DBS checks were due to be carried out every 2 to 3 years and this meant 6 staff members DBS checks were out of date and the system to have oversight of this did not identify this. We identified ineffective processes to support staff development and identify learning needs. Whilst there wasn’t a framework to determine the role specific training and when training should be completed and refreshed, most staff had completed the required training. However, reception staff were not provided with training or guidance on how to identify urgent medical conditions if patients reported specific high-risk symptoms. We also found staff had not had training in learning disability and autism, including how to interact appropriately with autistic people and people who have a learning disability (a legal requirement introduced in July 2022 as part of the Health and Care Act 2022). On review of staff records, we found an inconsistent approach for managing staff appraisals. There was a risk that the support and development needed by staff was not being identified through appraisals as part of a system of governance to enable them to carry out the duties they are employed to perform. For example, some staff reported they did not receive support via regular appraisals or performance reviews as part of identifying development needs.

People’s feedback in relation to the infection prevention and control (IPC) was mixed. In September 2023, CQC received feedback from a patient which reported infection prevention concerns which included reference to the general cleanliness of the practice. This did not align to other people’s experience we received or our observations on the day of the site visit.

Staff told us they had completed infection prevention and control (IPC) training and confirmed a practice nurse was the lead for IPC. We spoke to the lead, and they confirmed they led on IPC across all 3 sites and had worked with the IPC lead from the (Integrated Care Board) ICB to complete IPC audits, the most recent of which was completed in May 2024 for the main site.

We found all areas of both sites visited (the main site and 1 of the branch practices), including the GP consultation room, the nurse treatment room and the waiting area were visibly clean. We also saw the arrangements for managing waste and clinical specimens kept people safe.

There were processes to manage IPC across all 3 sites. This included processes to manage the general cleanliness, potential infection risks, immunisation status of staff and healthcare waste. However, the supporting correspondence of these processes were unclear. For example, the documentation submitted was unclear if the 2 other sites were included in the May 2024 IPC audit, and the actions following the audit did not reference any dates or how the action was to be completed.

People’s feedback in relation to the safe management of their medicines was limited. However, from the feedback we reviewed, we found there was mixed response from patients relating to making repeat prescription requests. Some people told us they had a good response when making repeat prescription requests whilst others said there has been a recent increase in delays and they have had to chase up prescriptions.

Staff and leaders explained there were processes for monitoring patients’ health in relation to the use of medicines including high risk medicines (for example, warfarin, methotrexate and lithium) with appropriate monitoring and clinical review prior to prescribing. Staff told us they had a system in place to ensure the safe prescribing of the patient’s repeat medicines. However, our findings indicated these processes were not always followed.

We observed medicines were stored appropriately and securely. This included monitoring to ensure medicines were stored at appropriate temperatures. We looked at the log used to monitor emergency medicines and equipment. This was a checklist that contained expiry dates for all the contents of each medical emergency bag. Paper prescriptions were stored safely in a locked cupboard and a log was used to monitor which batch numbers were removed, by whom and to which site. However, the key to access prescription stationery at a branch site was stored insecurely.

There were processes which ensured medicines were stored safely and securely with access restricted to authorised staff. This included processes for the appropriate authorisations to administer medicines (including Patient Group Directions or Patient Specific Directions). There were processes in place to manage and optimise medicines, however the practices processes to medicines did not reflect current and relevant best practice and professional guidance. There was evidence that the process for managing safety alerts, specifically alerts from Medicines and Healthcare products Regulatory Agency (MHRA) were not in place. For example, our remote clinical searches identified 40 patients of child-bearing age had been prescribed a teratogenic drug (a drug which can cause birth defects) in the last 3 months. We reviewed 4 patient records and found none had been advised of the risks and need for effective contraception as set out in the alert.

The CQC GP Specialist Advisor completed a series of remote searches on the practice’s clinical record system. These searches were completed with consent and to review if the practice was assessing and delivering care and treatment in line with current legislation, standards and evidence-based guidance – this includes guidance from the National Institute for Health and Care Excellence (NICE), referred to as NICE guidance. These searches demonstrated the provider did not ensure consistent delivery of evidence-based care as systems and processes were not established and operated effectively. For example: 138 patients had been prescribed aldosterone antagonist + ACEI/ARB (monitoring of blood electrolytes is essential in patients prescribed a potassium-sparing diuretic and an angiotensin converting enzyme inhibitor (ACEi) or an angiotensin receptor blocker (ARB) for heart failure). The searches indicated all 138 patients had not been monitored correctly. We reviewed 5 of the 138 patient records in detail and identified none had been monitored in line with NICE guidance (monitoring during treatment, more frequently if side effects are present with at least an annual blood pressure check). We brought this example and other examples of poor monitoring and management of medicines to the attention of the provider immediately; we were not assured any remedial action had been completed.