Drs Leung, Mallick, Sherrell & Hobbs

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 all quality statements under the Safe key question. This means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment, we rated this key question Inadequate. At this assessment, the rating has changed to Good. This meant people were safe and protected from avoidable harm. During our assessment of this key question, we found incidents were investigated openly and transparently. Actions were recorded and learning was shared with staff to mitigate the future likelihood of incidents reoccurring. Staff were confident in responding to safeguarding concerns and had received training relevant to the role. People received co-ordinated and joined up care when transitioning between healthcare services through the effective management of referrals, correspondence between providers and regularly reviewed local secondary care pathways. Recruitment checks were carried out in accordance with regulations and assurances were provided relating to the fit and proper persons employed. The practice ensured workforce planning arrangements were in place and staff were supported in their roles, including training, appraisal and relevant supervisions to provide safe care and treatment. During our clinical searches, although templates were available for monitoring patients prescribed high-risk medicines, these had not always taken place. The practice had an action plan in place to ensure patients would be monitored to continue safe prescribing of their medicines. More information can be found within evidence category findings.

This service scored 72 (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. From the feedback we received we saw no indication of concern in this area.

Staff were encouraged to raise concerns when things went wrong. They told us that significant events, complaints and examples of patient feedback were shared and discussed during regular all-staff meetings. Staff felt there was an open culture and understood their duty to raise concerns and report incidents. Leaders were able to share examples of how the practice resolved and investigated incidents.

There were policies and processes in place to record, investigate and take action from incidents and complaints. These were discussed in monthly meetings and minutes made available to staff who were unable to attend. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support in line with the duty of candour. Learning from incidents and complaints resulted in changes that improved care for patients.

Feedback from the Patient Participation Group (PPG) highlighted they were listened to, valued and had seen positive changes to improve patient experiences. For example, the practice had reviewed local care pathways including resources within the Primary Care Network (PCN). The PPG noted positive feedback in relation to the practice’s response to acting upon correspondence from secondary care providers and referrals demonstrating effective local care pathways. The PPG work with the provider to understand, better reflect and respond to patient needs.

Leaders told us that they worked with stakeholder organisations such as secondary healthcare providers to establish and maintain safe systems of care for patients. For example, the service reviewed referral pathway outcomes to ensure patients received co-ordinated and joined up care. They also told us that continuity of care for patients was important and that they achieved this through collaboration with others. For example, staff used a clinical decision support tool to log and monitor urgent referrals and this included input from external professionals involved in the patient's care. Staff we spoke with understood the referrals processes and how to manage correspondence.

We spoke with the NHS Hampshire and Isle of Wight Integrated Care Board ahead of this assessment. From the feedback we received from them there was no indication of concern in this area.

Policies and guidance were in place to support workflow and pathways for appointments, referrals, records and correspondence. The practice had a system in place for processing new patient information and summarising of notes. The practice had kept up to date with patient summarising to ensure accurate information was available for clinicians. 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.

As part of the assessment process, we asked the practice to invite patients to share their experience of the service. From the feedback we received we saw no indication of concern in this area.

Staff told us they had received appropriate training in safeguarding children and adults, health and safety and emergency response to undertake their role safely. A safeguarding policy was in place and accessible to all staff on the practice’s computer system. Staff knew who the safeguarding lead in the practice was and how to raise concerns. There were safe systems and processes in place to ensure children had been appropriately followed up with when they failed to attend appointments.

We spoke with the NHS Hampshire and Isle of Wight Integrated Care Board ahead of this assessment. From the feedback we received from them there was no indication of concern in this area. Feedback from the community mental health team highlighted that vulnerable people were supported to protect them from harm where possible and the practice worked as part of a multi-disciplined team to develop treatment plans. Learning was shared with staff based on regular evaluation of care.

There were designated safeguarding children and adult leads at the practice. There were monthly multi-disciplinary meetings where safeguarding issues were discussed and these were attended by GPs and members of the nursing team. External stakeholders were invited to safeguarding meetings where relevant. Systems were in place to appropriately refer people to local authorities safeguarding teams and information was shared amongst community teams where required. Policies for chaperoning and safeguarding were in place and accessible to staff. 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) checks to ensure they would be appropriate to undertake this role. We reviewed a sample of patient records as part of our remote clinical searches and found care plans noted how people were to be supported to remain safe.

Feedback from local care homes indicated that people had access to routine medical care. The practice home visiting team were able to provide urgent and acute care needs effectively.

Staff told us there were enough staff to manage workloads to prevent further backlogs of tasks and working excessive hours. The practice had a dedicated workflow team comprised of administrative staff which supported correspondence and patient communications. Staff told us urgent tasks were raised to GPs based on information escalated by Out of Hours and 111 services, in particular, for patients who were required to be seen in-hours by the practice based on their symptoms and clinical presentation. Leaders demonstrated the arrangements for reviewing abnormal results were prioritised to ensure patients were followed-up in a timely way. For example, we observed the practice’s pathology clinical system mailbox and identified abnormal test results were assigned to the duty GP for review on the day and correspondence was picked up to prevent delays to care and treatment. Staff were able to describe their roles and responsibilities to manage risks associated with workflow and patient correspondence.

Staff rotas were completed with oversight of cover where required, so that should a clinician be absent at short notice, their pre-booked appointments could be put into protected available same day slots with another clinician. There were effective staffing arrangements to ensure in the event of emergency, the risk of unsafe practice was mitigated to prevent lone working. There were systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment. We identified processes to monitor delays in referrals and the practice carried out audits to ensure ‘two week wait’ (2WW) cancer referrals had been booked with secondary care providers as a safety netting mechanism. 2WW cancer referrals are urgent referrals used to investigate symptoms to detect cancer.

Staff we spoke to were confident in responding to emergency situations. They knew where the emergency medicines and resuscitation equipment were stored and how to support people. Staff reported positively on their colleagues and working environment and regarded it as a safe place. Staff told us they had undertaken required mandatory training in respect of health and safety, such as fire safety training, and that they had no concerns related to health and safety in the practice. Staff confirmed that fire alarm tests and emergency evacuation drills had been undertaken and this was supported by records we examined.

During the on-site visit, we identified that on the practice premises, there were designated disabled car parking spaces and areas suitable to leave mobility aids and pushchairs. Entry into the practice was via a ramp and electronic sensor sliding doors. Staff were available to support patients if required. The waiting area was clear with room to manoeuvre around furniture. A selection of seating was available to people including chairs with armrests to assist people with limited mobility. Wheelchairs were also available should they be required. There was a large disabled toilet with changing facilities and appropriate handwashing facilities and fitted with an alarm. Separate room isolation facilities were available should patients present with potential contagious illness and a separate room available should people wish to feed their child in privacy. There was a spillage kit accessible to staff and staff knew where this was and how to use it.

The provider had established effective systems to identify, manage and mitigate environmental risks to people. For example, the practice had conducted environmental risk assessments (including legionella testing and portable appliance testing) to ensure staff and people were safe and revised them annually or in response to changes. Staff completed daily inspections of each practice to ensure risks were identified, recorded and addressed, all overseen by the management team.

As part of the assessment process, we asked the practice to invite patients to share their experience of the service. From the feedback we received we saw no indication of concern in this area. People could feed back their experience of the service via the Friends and Family Test (FFT) survey. We reviewed patient feedback and found that people reported having confidence in their healthcare practitioners. We identified examples of positive feedback relating to staff such as clinicians listened to people and provided good quality care and treatment. Both clinical and administrative staff were described as professional and friendly.

There were sufficient staff to ensure people’s records were kept up to date. Leaders told us the administrative team managed summarising and clinical coding. We found staff had the most up to date clinical information to support their knowledge and inform treatment decisions and care planning. Staff told us that there were opportunities to ask for support, raise concerns and appraisals were carried out annually. Staff could discuss clinical queries in relation to their medicine prescribing or care and treatment planning with leaders who they said had an ‘open door’ policy. The duty GP held weekly clinical supervision sessions to discuss performance, care and treatment. Leaders told us that staff rotas were planned 4-12 weeks ahead of time. Administrative staff were deployed effectively to support the duty team and manage patient demand from urgent online and telephone requests.

All recruitment and Human Resource (HR) records were kept in-line with practice policy and Schedule 3 requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We carried out a review of the provider’s recruitment checks in relation to 4 members of staff and information was available and up to date in line with practice policy. Staff received a formal induction relevant to their role and responsibilities and were supported through ongoing appraisals and supervisions, including prescribing checks for relevant clinical staff. Competency checks were conducted for the nursing team.

As part of the assessment process, we asked the practice to invite patients to share their experience of the service. From the feedback we received we saw no indication of concern in this area.

Staff told us that they had access to appropriate and clean facilities and equipment. They knew who the infection prevention and control (IPC) lead was and how to raise concerns. The practice had an operations manager and a lead nurse who demonstrated awareness to the actions taken in response to infection prevention and control audits for the premises. Staff who handled clinical specimens told us that they had received guidance on how to do this safely.

During the on-site visit we found the practice was clean, tidy and hand washing facilities were available throughout the premises. We inspected and were assured that clinical rooms and equipment had been cleaned on a daily basis. Cleaning schedules and records were in place for various areas such as clinical rooms and refrigerators where vaccines and medicines were stored. Appropriate personal protective equipment was available to staff.

There was an infection prevention and control (IPC) lead for the practice who carried out weekly spot checks of cleanliness and reported any issues to staff and to the external cleaning company that were contracted to clean the practice. Staff received IPC training and this formed part of their mandatory training requirements. There was an IPC policy in place. Clinical waste was appropriately managed by an external company. The operations manager and lead nurse had resolved areas of risk previously identified within the annual IPC audit. Staff followed safe clinical waste procedures. Sharp container boxes were dated and signed in use and were not overfilled. Clinical waste bins were securely stored and not accessible to the public.

Feedback from people using the community mental health service was mainly positive but highlighted that requests of medication changes (electronically) were not always processed in a timely manner by the practice. The community mental health service raised that a regular joint working forum would help share and resolve queries and clinical information, which currently was not formally carried out. The practice had increased patient uptake of cervical screening over the past year and had proactively worked to increase uptake and education in this area. For example, the practice had dedicated extended access arrangements for working people to attend appointments on Saturdays in which capacity was provided by a GP and a nurse practitioner. The practice had also started to implement dedicated female health clinics where patients could book appointments accessibly online and via the NHS app. Feedback from the community nursing team was positive and a regular multi-disciplinary team meeting was in place to discuss patients who were vulnerable or who regularly used community nursing care in line with the practice.

Leaders were able to demonstrate that there was an effective system to ensure safety alerts were acted upon in a safe way to patients. During our clinical searches we found patients who were affected by medicine safety alerts were contacted to inform them of the risks and prescriptions were reviewed appropriately. Staff were aware of how the practice managed information changes to a patient’s medicine including changes made by other services, for example, the out of hours provider (OOH). Leaders told us performance in relation to medicines outcomes had been monitored through discussions in clinical meetings and through the practice quality improvement team. The practice had an action plan in place to ensure patients were monitored through routine reporting and recall management to continue safe prescribing for patients.

During our on-site visit we found Patient Group Directions (PGD) and Patient Specific Directions (PSD) were in place which relevant staff worked to. Prescription stationery was logged and stored securely. Medicines were stored securely throughout both sites. The practice held appropriate emergency equipment and emergency medicines at the main practice and branch site. The practice maintained appropriate fridge temperature records where vaccines were being stored and observation of variances of temperature had been addressed and logged.

Appropriate medicine reviews were not consistently carried out for some patients receiving high-risk medicines. At the time of assessment, the practice were working towards establishing and embedding systems to ensure the safe prescribing and monitoring of medicines. During our remote clinical searches, we determined not all patients who had been prescribed high-risk medicines had been appropriately monitored and reviewed. For example, we identified 11 patients who were prescribed Lithium (a medicine used to treat certain mental illness), of which 3 had not received the appropriate blood monitoring in last 3 months and their Body Mass Index (BMI) within 6 months in line with national guidelines. We saw an example of a patient who was undertreated lithium medicine (used to treat mental health and mood disorders) and the practice had not identified this during a medicines review or when carrying out blood monitoring for their condition. These episodes of care were carried out by non-medical staff members (ANP or pharmacist) where care and treatment may have been monitored as part of the practice’s supervision process to ensure safe care and treatment. Safety Alerts had been acted upon appropriately according to practice policy.

There were not always effective systems in place to ensure all patients were being safely monitored. During our clinical searches we identified 12 asthma patients who had received 2 or more ‘rescue’ inhalers in the past 12 months. We reviewed 5 patients, all of which had received annual asthma management plan and escalation plan if the patient gets ill, however, this was between 1-2 weeks after the acute exacerbation, outside of the 48-hour national guideline. There was evidence all patients received a review of inhaler technique and annual asthma review taken place. The practice had an action plan in place to review and improve their clinical monitoring systems. We saw examples of actions taken as part of 2-cycle clinical audit activity, such as ensuring prescribing of antibiotics for urinary tract infections (UTI) as well as medicine safety updates in relation to statins (group of medicines that can help lower cholesterol in the blood) was monitored in accordance with national guidelines. We found the practice had implemented regular 2-cycle audit to monitor patients with a potential missed diagnosis of type 2 diabetes. Coding of type 2 diabetes diagnosis is important to ensure clinical checks (blood pressure, feet and eyes), prescribing of diabetic medications and regular blood monitoring of HBA1C and urine ACR and provision of lifestyle advice including diet exercise and smoking cessation. During each cycle of the audit, the practice had identified patients with a potential missed diagnosis and reviewed monitoring requirements in line with national guidelines to ensure safe care and treatment. The practice had appropriately coded patients based on diagnosis criteria.