Tieve Tara Medical Centre

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

At the inspection in July 2023, the practice was rated requires improvement in the key question safe. Concerns included patients not receiving appropriate monitoring and follow up, patients not being correctly diagnosed with long-term conditions when required, medicines safety alerts not being appropriately actioned, clinical supervision of non-medical prescribers being limited and not formalised, and fire evacuation drills not being undertaken. At this assessment we found that there were still concerns around the monitoring of patients and with the actioning of safety alerts. In addition, although clinical staff received support and formal supervision, this did not include the undertaking of prescribing audits for non-medical prescribers. We found that improvements had been made with diagnosing patients with long term conditions, and that the practice had implemented regular fire evacuation drills. Complaints and incidents were discussed and used to make improvements. There was a designated safeguarding lead and appropriate safeguarding processes in place. The premises were clean and tidy. Staff understood the importance of keeping people safe and how to escalate any concerns. However, there were gaps in processes for health and safety risk management, which included evidence of remedial actions not always being addressed in a timely manner. Some staff had not received or were not up to date with required training.

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.

As part of the assessment process, we asked the practice to invite patients to share their experience of the service. There was no feedback to indicate concern in this area.

Leaders told us about the processes in place for actioning medicine safety alerts. They told us these were disseminated and processed by relevant staff. However, as part of this assessment we reviewed 2 safety alerts and found that 1 of these had not been appropriately actioned. We were also told about the ways in which learning was used to improve services. This included learning from significant events, complaints, audit findings, and feedback. An example of this was where a member of staff administered an injection to a patient, and subsequently noticed that the injection had passed its expiry date. The practice contacted specialists for advice, notified and reviewed the patient. Improved systems to record expiry dates prior to administering medication and to clearly label medications that were nearing expiry were implemented.

There were policies and processes in place to record, investigate and take action from incidents and complaints. These were discussed in clinical meetings and minutes were made available to staff. There was a process in place for recording and sharing medicine safety alerts. The ineffective actioning of safety alerts was raised as a concern in our previous inspection in July 2023. A review of clinical records on this assessment indicated that safety alerts were still not always actioned in line with guidance, as evidenced in 1 of the 2 safety alerts that we looked at. For example, we reviewed 5 patients prescribed Topiramate (a medicine used to treat migraines) and found that action had not been taken to ensure these patients fulfilled the conditions of a Pregnancy Prevention Programme. After the assessment the practice had put a plan in place to contact all affected patients and carry out the necessary risk assessments and actions.

As part of the assessment process, we asked the practice to invite patients to share their experience of the service. There was no feedback to indicate concern in this area.

Leaders told us that they worked with others to establish and maintain safe systems of care for patients. They told us that measures were in place to monitor referrals, in particular those related to cancer 2-week waits to track the progress of the patient following referral. Staff we spoke with understood the referrals processes and how to safely manage medical correspondence.

As part of the assessment process, we asked the NHS West Yorkshire Integrated Care Board to share their experience of the service. There was no feedback to indicate concern in this area.

Protocols were in place to support workflow and pathways for appointments, referrals, records summarising and correspondence. There were processes to monitor and manage care when patients were moved between services, such as after referral to secondary care, or admission to hospital. A review of the practice clinical system, which formed part of this assessment, indicated that patient test results were being managed in a timely manner. There was however a backlog of 217 patient records to be summarised. Actions taken to address this included support and oversight of the process by a recently recruited staff member. After the assessment the practice told us they had reduced this backlog to 88 records.

As part of the assessment process, we asked the practice to invite patients to share their experience of the service. There was no feedback to indicate concern in this area.

Staff told us how they used the clinical system to record and alert others to safeguarding concerns, and how they escalated any concerns. Staff explained their responsibilities around reporting and recording incidences of female genital mutilation.

As part of the assessment process, we asked the NHS West Yorkshire Integrated Care Board to share their experience of the service. There was no feedback to indicate concern in this area.

There was a designated safeguarding children and adult lead at the practice and safeguarding policies containing relevant contact details and escalation processes. At the time of the assessment most staff were up to date with training in these areas. Some staff who were listed as chaperones had not received any formal training or refresher training for some time, however they were able to explain how to carry out this role appropriately. After the assessment we saw that the practice had arranged chaperone training for staff. There were monthly meetings where safeguarding issues were discussed, and these were attended by practice clinical staff as well as by a midwife.

As part of the assessment process, we asked the practice to invite patients to share their experience of the service. There was no feedback to indicate concern in this area.

Staff we spoke with knew where to locate emergency drugs and equipment and were able to explain how to act safely in an emergency, including alerting clinical staff and emergency services. Some non-clinical staff told us they were not aware of ‘red flag’ presenting complaints. There was no evidence of formal sepsis awareness training for staff, however we were told that information was available in the reception area to support non-clinical staff.

There was a resuscitation policy in place. We saw that checks on emergency drugs and equipment were carried out and recorded regularly, and that risk assessments had been carried out for recommended medicines that were not stored at the practice. Staff received training in basic life support and anaphylaxis. However, sepsis awareness training did not form part of the mandatory training schedule. After the assessment the practice arranged for staff to receive this training.

Leaders told us that they had developed and adopted health and safety management processes to ensure the safety and wellbeing of patients, staff and visitors to the practice. However, we found there was a lack of oversight of these processes as action was not taken in a timely manner. Staff informed us that they had undertaken required mandatory training in respect of health and safety, however some staff were not up to date with this training. Staff we spoke with told us that they had no concerns related to health and safety in the practice.

We saw that the premises were in a good structural condition, and that equipment was maintained regularly, stored safely and was suitable for use. For example, fire extinguishers had recently been serviced, and clinical equipment had been calibrated to ensure correct operation. There was a lift available for patients to access the first floor. There was appropriate signage in place, such as for fire doors and escape routes.

There were policies and processes in place for health and safety risk management. For example, equipment was appropriately maintained, regular fire alarm tests and evacuation drills were carried out, and risk assessments were undertaken. However, there was evidence that remedial actions were not always carried out in a timely manner. For example, an electrical installation condition report from 16 October 2024 showed that the overall assessment of the installation was unsatisfactory, with urgent actions required. We saw that the practice had not requested for this work to be carried out until 22 November 2024. At the time of the assessment this work had not been started. In addition, electric roller shutters repair work identified in a January 2024 service report had not been requested by the practice until July 2024. At the time of the assessment this work had not been started. A Legionella action plan had recently been created by the practice to address several high-risk actions that were identified in a January 2023 risk assessment. In addition, the practice told us that regular water temperature testing took place. However, at the time of the assessment this could not be evidenced. The practice had appointed staff to key roles such as fire marshals.

As part of the assessment process, we asked the practice to invite patients to share their experience of the service. There was no feedback to indicate concern in this area.

Leaders told us about the ways in which they ensured staff were qualified and skilled to carry out their roles, and the support that they offered them. They told us that recruitment was underway for a third salaried GP. Most staff told us they had enough support to carry out their role and could seek further guidance from senior staff when needed, however, several staff told us that there were not enough non-clinical staff in place to safely manage workloads. The practice told us they actively monitored staffing levels, for example by looking at numbers of calls and appointments, and would seek to recruit further staff based on this data. They told us this was in line with their capacity and access plan.

Policies on recruitment, induction, and staff appraisals were in place. There was an induction pack available for locum GPs and this included key contacts and referral processes. We reviewed 3 staff personnel files as part of this assessment and found that documentation was generally in line with guidance. This included Disclosure and Barring Service (DBS) checks, immunisation records and appraisal records. Clinical staff received regular sessions of supervision however this did not include undertaking prescribing audits for non-medical prescribers. The practice told us they would make arrangements to undertake these audits regularly.

As part of the assessment process, we asked the practice to invite patients to share their experience of the service. There was no feedback to indicate concern in this area.

Feedback from staff informed us that they had a good understanding of infection prevention and control (IPC). Staff knew who the IPC lead was and how to raise IPC concerns. Staff who handled clinical specimens told us that they had received guidance on how to do this safely.

We found the practice premises and equipment to be tidy and clean. Cleaning records were in place and the cleaner’s cupboard was tidy and contained appropriate equipment and cleaning materials. Appropriate personal protective equipment was available to staff.

There was an effective approach to assessing and managing the risk of infection. There was an infection prevention and control (IPC) lead for the practice who carried out monthly hand hygiene audits and yearly IPC audits, for which any actions were completed. There was an IPC policy in place and staff received yearly IPC training. Clinical waste was appropriately managed by an external company.

As part of the assessment process, we asked the practice to invite patients to share their experience of the service. There was no feedback to indicate concern in this area.

Leaders told us that performance in relation to medicines outcomes were closely monitored through discussions in clinical meetings and through medicines audits. For example, an audit in response to identification of high prescribing of a particular medicine had recently been undertaken, and this included inviting patients to discuss their medication needs with a view to reduction. A subsequent re-audit showed a reduction in the number of patients on a repeat prescription, as well as reduced doses for some patients. Staff told us they received appropriate training in the management of vaccines. Some staff felt they did not have enough clinical supervision for their prescribing.

The ineffective monitoring of patients, including those on high risk medication, was raised as a concern in our previous inspection in July 2023. As part of this assessment a CQC GP specialist advisor (SpA) undertook searches of patient records on the practice’s clinical system and found that there were still some concerns around the monitoring of patients. Findings included: Direct oral anticoagulants (DOACs): 30 out of 122 patients were identified as not having the required monitoring. Of these 122 patients, 108 had not had a check of Creatinine Clearance (CrCl) in the last year. After the assessment the practice had put a plan in address to this, including contacting patients to arrange checks, as well as ongoing monitoring. Methotrexate (a disease-modifying anti-rheumatic drug): 1 out of 15 patients was identified as not having required monitoring in the last 6 months. However, there was evidence that the practice had contacted the patient a number of times to invite them for monitoring. Azathioprine (a disease-modifying anti-rheumatic drug): 1 out of 5 patients was identified as not having required monitoring in the last 6 months. Medicines usage: There were 405 patients on the asthma register, of which 23 patients were identified as having received 12 or more Short-Acting Beta-Agonist (SABA) inhalers in the last 12 months, and having no chronic obstructive pulmonary disease (COPD). No significant issues were identified with the 5 patients reviewed. Medication reviews: There had been 447 medicines reviews undertaken in the last 3 months. Of the 5 we reviewed, there were no concerns identified.

There was a medicines management and a cold chain policy in place. Medicines within the practice were effectively ordered, stocked and monitored. There were Patient Group Directions and Patient Specific Directions in place which relevant staff worked to. There was a process in place to ensure prescription stationery was logged and stored securely. Refrigerators used to store vaccines and medicines were regularly cleaned, temperatures were monitored and logged, and products were appropriately stored within them. The practice participated in the Lowering Antimicrobial Prescribing (LAMP) audit and had recently attended a prescribing meeting with the primary care network medicines optimisation lead, to focus on their prescribing performance.

Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. Prescribing data reviewed as part of our assessment showed that practice performance was in line with national averages for 4 out of 6 prescribing indicators, whilst the remaining 2 indicated slightly higher prescribing. For example, data from July 2023 to June 2024 showed that the percentage of Co-amoxiclav, Cephalosporins and Quinolones prescribed was at 9%, compared to the national average of 7.6%.