Southway Surgery

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 all 8 quality statements from this key question. We found the practice did not have an effective system to learn and make improvements when things went wrong, the practice did not have clear systems, practices and processes to keep people safe and safeguarded from abuse, there were gaps in systems to assess, monitor and manage risks to patient safety and the practice did not have systems for the appropriate and safe use of medicines, including medicines optimisation.

This service scored 56 (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 they were not offered opportunities to provide feedback and they were not aware of how to make a complaint.

Some staff we spoke with or received feedback from told us they were aware of how to raise a significant event, but they did not feel confident in doing so as they were concerned staff would be blamed for mistakes. In addition, some staff told us they were not made aware of learning or outcomes from significant events.

The system to learn and make improvements from significant events was not always effective. We found only 6 significant events had been logged in the last 12 months. We found evidence which indicated that significant events or incidents were not always investigated in a manner which identified the cause of risk to patients and did not provide mitigation against further risks occurring. For example, we identified a significant event where a controlled drug had been prescribed inappropriately on 7 occasions in 2022 and whilst the practice made some changes to their prescribing processes as a result of their investigation, there was no learning identified for the authorising prescribers to ensure this risk did not reoccur.

Patient feedback did not indicate any concerns with referrals to secondary care or other services.

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.

Feedback from partners highlighted challenges in the provision of a collaborative, joined up approach to managing patient care. For example, no measures had been put in place to cover the lead GP role for over a year at a local care home which led to a lack of continuity of care for residents. In addition, we were told a weekly ward round had previously been in place and residents engaged well with this; however, this was stopped in December 2023.

There were processes to manage patient pathways or transitions including referrals and sharing and receiving of information with external health services. Processes were in place to deal with incoming correspondence, and we found clinical correspondence and test results were up to date. The practice had 120 tasks awaiting completion, however, we noted these were all in progress. Tasks are used within general practice to manage information and can include administrative actions as well as patient-specific actions, for example, to send referrals and review test results. The practice had a 2 week wait referral procedure with a dedicated member of staff who had oversight of any delays to appointments and could follow up referrals and escalate as necessary.

Patient feedback indicated most patients were aware of the chaperone system and felt able to access a chaperone if needed. Results from the national GP patient survey 2024 demonstrated that 61% respondents felt the healthcare professional they saw or spoke to was good at considering their mental wellbeing during their last general practice appointment. However, this was below the local average of 75%.

Staff understood their safeguarding responsibilities however, some staff told us they did not feel confident in what action to take if they thought a person was at risk of potential harm. We also identified 4 staff members, including leaders, were not aware of who the safeguarding lead, deputy safeguarding lead and safeguarding administrator were, as stated in the safeguarding policy.

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.

The practice did not have clear systems, policies and processes with regards to safeguarding. The July 2024 safeguarding policy and a recently completed safeguarding process audit contained different contact details for both children and adults and the policy listed incorrect contact details for referral information. For example, sexual assault referral centre (SARC) contact details were provided, however, this had been incorrectly titled as ‘police child abuse investigation unit’. There was a risk that staff would not be able to take effective and timely action if they were concerned about potential harm to a vulnerable adult or child. We also found 2 staff members were overdue adult safeguarding training and 3 staff members were overdue child safeguarding n training to the appropriate level for their role.

Patient feedback via the National GP Patient Survey 2024 indicated 95% respondents knew what the next step would be within two days of contacting their GP practice which was above local and national averages. However, 77% patients said they were involved as much as they wanted to be in decisions about their care and treatment, which was below local and national averages which were above 90%.

Leaders and staff told us they worked with patients to help them understand and manage risks so their needs were better met. For example, by using information leaflets and directing patients to health information on the practice website. Staff we spoke to were aware of actions to take if they encountered a deteriorating or acutely unwell patient.

Systems and processes related to risk management were not always operated effectively. For example: we found clinical risks in relation to patients prescribed high risk medicines, those that had long term conditions and those with a potential misdiagnosis. We found concerns during our assessment that some patients had not been monitored appropriately or followed up to ensure they were receiving safe care and treatment. The practice was equipped to respond to medical emergencies and all staff had completed sepsis awareness training. However, we found one non-clinical staff member was overdue basic life support training for both adults and children .

Staff informed us they had undertaken required mandatory training in respect of health and safety, such as annual fire safety training. Staff told us they had no concerns related to health and safety in the practice.

During our site visit we found the environment was clean and well maintained. Clinical equipment was calibrated at regular intervals, and we saw a fire drill had been completed in the last three months.

The practice did not have a clear system to respond to and monitor progress against fire, health and safety risk assessment actions. We reviewed a health and safety assessment completed on 1 July 2024 and identified 11 findings requiring action. Of these 11 findings, 5 had been identified as outstanding from the previous assessment conducted in November 2023, including a high priority concern that risk assessments did not cover the employed cleaning staff and their work activities. A further 5 findings had been identified as outstanding from the previous two health and safety assessments. For example, there were no specific risk assessments completed to comply with the Control of Substances Hazardous to Health Regulations (COSHH). This demonstrated the practice had not taken appropriate action to mitigate or eliminate identified risks to health and safety. A fire risk assessment was completed in February 2024 and identified three recommendations and two further actions. This included displaying oxygen notices on the entrance door and treatment room, and fire safety to be appropriately documented within the practice health and safety policy and procedure. We found some errors in the internally completed fire risk assessment, for example, the fire risk assessment had not identified an ongoing issue of storing combustible items in the plant room. This was a risk identified in the externally completed health and safety assessments both before and after the fire risk assessment had been completed. We requested evidence of how the practice monitored progress against the actions from the recent fire risk assessment, however, the practice did not provide a clear action log to monitor ongoing progress. The practice sent us information following the inspection to demonstrate that risk assessment relating to COSHH had been completed.

Patient feedback raised concerns about the urgent need for another permanent GP at the practice and told us there was a reliance on locum GPs which meant there was a lack of continuity of care for patients.

Staff told us there was a need for another permanent GP at the practice to improve appointment availability and felt senior managers needed to be present on a daily basis. Some staff reported they did not receive support via regular appraisals or performance reviews as part of identifying development needs.

The system for recording Disclosure and Barring Service checks (DBS) and DBS risk assessments for non-clinical staff with chaperone responsibilities was not effective. The system did not demonstrate which staff had a DBS check and leaders were uncertain which staff had DBS checks. We identified 3 risk assessments had been completed but contained little information regarding chaperone-related risks and did not contain a clear rationale for the decision not to have a DBS check as required by the practice chaperone policy. In addition, one of these DBS risk assessments had not been dated. The staff development policy stated staff should have an annual appraisal. However, from a 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, we found four staff members did not have an up-to-date appraisal and two of these staff members started in 2021 and 2022 and the log indicated they had never had an appraisal at the practice. We noted a further 6 staff only had their appraisal following our site visit.

All patient feedback we received as part of the assessment was positive about the cleanliness at the practice and did not report any infection, prevention and control concerns.

Staff we spoke to had a good understanding of infection, prevention and control (IPC) and they knew who the IPC lead at the practice was. Staff who handled clinical specimens were aware of how to carry out their role safely.

We found the practice premises and equipment to be clean, which protected people from the risk of infection. We also saw the arrangements for managing waste and clinical specimens kept people safe and sharps bins were signed, dated, safely sited and were not over-filled.

The practice had an effective approach to assessing and managing the risk of infection. There were policies for infection, prevention and control (IPC) however, we noted the annual statement on compliance with IPC practice was only created on 31/07/2024 after our site visit. We were provided with evidence of the last two IPC audits, most recently completed in April 2024. These audits clearly highlighted actions to ensure IPC compliance, for example, replacement of fabric chairs with wipeable surfaces. The provider had processes to assess the immunisation and vaccination status of staff and most staff were up to date with IPC training. However, we identified one nurse was overdue their training by 2 months and the practice told us this would be completed by the end of August 2024.

People’s experience in relation to the safe management of their medicines was limited. However, we received feedback from some patients and a local care home who highlighted concerns regarding the repeat prescription process. For example, we were told there had been occasions where wrong amounts of medicines had been issued by the practice, but once this was raised with the practice, the practice rectified the errors. From a review of the practice complaints log from the last year, we identified 11 complaints relating to prescribing of medicines. This included issues with being given differing advice on how to request medicines, delays in prescriptions, concerns about amount of medicines prescribed and a patient being prescribed medicines in error.

Staff and leaders told us that clinicians involved patients in assessments and reviews about the level and support they needed to manage their medicines safely. Leaders told us they had a system to ensure the safe prescribing of patient’s repeat medicines. However, our findings indicated these processes were not always followed. For example, we identified 3 examples of limited or no documentation provided by the authorising GP when prescribing medicines.

We observed medicines and vaccines were stored appropriately and securely. This included monitoring to ensure medicines were stored within correct temperatures. Emergency medicines and equipment were available. We found Patient Group Directions or PGDs were in place but had been authorised prior to all nurses signing. Patient Group Directions (PGDs) provide a legal framework that allows some registered health professionals to supply and/or administer specified medicines to a pre-defined group of patients, without them having to see a prescriber (such as a doctor or nurse prescriber). After this was raised with the practice, the practice told us they had made changes to avoid recurrence and were in the process of resigning and authorising all PGDs.

The provider did not have a clear process to ensure appropriate supervision was in place for the non-medical prescriber (NMP). In July 2024, the lead GP carried out their first minor illness audit as part of formal supervision of the NMP, which reviewed prescribing as part of this. However, no audits of the NMP’s prescribing had been completed since they had been employed in October 2022. This meant the provider had not undertaken appropriate supervision for the NMP as required to ensure they conducted their role safely and that patients received effective care and treatment. The process for managing safety alerts, specifically alerts from Medicines and Healthcare products Regulatory Agency (MHRA) were not always effective. For example, our clinical searches identified 3 patients prescribed both clopidogrel and omeprazole (omeprazole inhibits the effect of clopidogrel and should not be prescribed together). We reviewed these patient records and found 2 of these patients could be at risk of harm. This was highlighted to the lead GP who told us this would be reviewed urgently. Our clinical searches also identified 147 patients on Sodium-glucose co-transporter-2 inhibitors or SGLT-2 inhibitors (medication used to manage blood sugar levels) who required review as ketoacidosis advice had not been recorded. The practice sent us information following the inspection to show this had been completed.

Our clinical 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: Our clinical searches identified 23 patients as having heart failure and had been prescribed aldosterone antagonist (a diuretic medicine). Of these, 5 patients (21.7%) had been prescribed the medicine without the required monitoring. We reviewed these 5 patients in detail and identified none had been monitored in line with NICE guidance (monthly monitoring for first 3 months, then every 3 months for 1 year, and then every 6 months). One of the patients identified was overdue their monitoring by 9 months.