Hockley Farm Medical 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

During our inspection we found no immediate safety risks to patients however, there were some gaps in processes that needed to improve. Medicines and treatments were safe and met peoples needs in most cases, however there was further work required on ensuring patients taking regular medicines and requiring ongoing monitoring for their health were kept safe. Improvements were also needed within staff recruitment and training processes to ensure all staff at the service were appropriate for the role.

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.

Staff told us there were processes in place to raise incidents and complaints to ensure learning was captured to improve services. Staff were encouraged to raise incidents and speak up around concerns. Leaders told us that there had been an increase in complaints recently which were reviewed during the inspection.

We reviewed processes for significant events and complaints within the practice and found there were good processes in place to capture investigations and learning outcomes from incidents. However, there was a lack of assurance that recent incidents had been appropriately discussed with team members for their awareness. There were also some events which had been discussed within team meetings but were no full investigation recorded.

We found there were some systems to ensure patient safety. However, due to some staff shortages or excessive workloads there were some gaps found in ensuring patients received the monitoring they required. For example, we found that some patients taking anticoagulation medicines had not always had the correct monitoring tests completed to ensure that patients were receiving effective treatment.

The partners told us that there were plans in place to ensure patient safety was prioritised but were aware that some management responsibilities needed to be further embedded to provide support to staff. For example, it was not clear who had oversight of the pharmacy team or who was responsible for staff training within the practice in the absence of a practice manager.

Some areas of patient care such as medication reviews or ongoing monitoring of regular medicines were not always being completed in line with best practice guidance to ensure that patients were receiving up to date treatment. We were told this was due to recent staff departures and excessive workloads.

The practice had designated staff to deal with safeguarding issues and we saw evidence the practice utilised a system to recognise patients with a safeguarding concern on the clinical system. Staff training was not always in line with required level of training in line with their role.

The practice held meetings regarding vulnerable patients and discussed what actions were necessary to keep patients safe. However, we did not see a continuous review of all patients regularly recorded within the safeguarding meetings.

Leaders within the practice were generally aware of risks and had some systems to ensure risks were dealt with. However, there was a lack of shared direction within leaders which was prohibiting changes to be made within the service and risk management to always be completed.

We found that due to staff shortages and excessive workloads, there were gaps in some areas of work meaning that risks were not always being adequately reviewed. For example, safety alerts, staff training, recruitment processes and monitoring patients taking regular medicines were not always reviewed in a timely way. The practice pharmacy team was responsible for completing medication reviews of patients taking regular medicines. We saw these were being completed, however there was a lack of information to show what had been reviewed and if discussions had taken place with patients within these reviews.

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

It was not clear who was responsible for oversight of staff training within the practice.

We reviewed staff training records and found evidence that not all mandatory training had been completed for staff. Some mandatory training requirements were not in line with best practice guidance. For example, safeguarding training was not in line with the intercollegiate guidance. We saw evidence of new staff who had not completed any training modules for a number of months. There was also evidence of long standing staff who had not received training updates in a timely manner.

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.

The practice had systems and processes to ensure the safe management of medicines. We found that staff had a good knowledge of current and relevant best practice guidance. Some staff told us that due to high workloads, there were gaps in some areas of medicines optimisation such as conducting structured medication reviews.

During our onsite assessment, we reviewed medical fridges and emergency medicines and found systems in place to ensure medicines were appropriately stored and ready to use.

During our assessment we conducted remote clinical searches which allowed us to review patients medical records to understand the practices processes and ensure they were receiving safe and effective care. We found patients were being well managed and medicines were mostly being appropriately prescribed. We found that patients results were being picked up on and followed up to ensure timely diagnosis. We found that the practice had systems for patients taking high risk medicines, however there were some gaps around reviewing some patients who required monitoring in line with guidance.

There were systems in place to receive and act upon safety alerts, however due to staff shortages within the practice pharmacy team, these had not been completed since February 2024. This meant that the practice could not provide assurance that patients had been reviewed appropriately. The practice pharmacy team was also responsible for completing medication reviews of patients taking regular medicines. We saw these were being completed, however there was a lack of information to show what had been reviewed and if discussions had taken place with patients within these reviews.