Matching Green 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

At our previous inspection in June 2022, the practice was rated inadequate at providing a safe service because they were unable to demonstrate good governance to protect patients from the risk of harm in relation to safeguarding, managing and oversight of test results, information relating to patient safety, monitoring of patients on high risk medicines, prescribing concerns and the effectiveness of the management of patient safety alerts. We assessed a total of 8 quality statements from this key question. We have combined the scores for these areas with scores based on the rating from the last inspection, which was inadequate. Our rating for this key question is good. We found a positive culture of safety, and staff took all concerns seriously. When things went wrong, staff acted to ensure people remained safe. Managers investigated all reported incidents to reduce the likelihood of them happening again. We saw improvements in the managing and oversight of test results. We undertook clinical searches on the practice clinical systems that showed improvements in medicines optimisation, in particular in the monitoring of patients on high-risk medicines. We identified further strengthening of systems were required in the management of some patients with a long term condition, systems for consistently actioning safety alerts in line with national guidance, the co-ordination of multidisciplinary team (MDT) safeguarding meetings and recruitment and training checks for external staff. Leaders provided assurances during the assessment that actions were either taken or there were plan in place to make the improvements required.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. Information to support people to make a complaint was available on site and on the practice website. The practice did not have an active Patient Participation Group (PPG) to continue to seek the views of people who used the service, this was an area identified for improvement at the last inspection. The practice had taken action to try to reinvigorate the group following the COVID-19 pandemic and continued to work with other local practices to implement a Primary Care Network (PCN) wide PPG.

Managers encouraged staff to raise concerns when things went wrong. We received 14 staff feedback forms, overall staff described an open learning culture. Staff attended and had access to the monthly team meeting minutes where incidents were discussed. Staff felt there was an open culture, and that safety was a top priority and knew who to speak with if they wanted to speak up. Staff described the Practice Manager as supportive, and leaders encouraged an open-door policy.

At the last inspection we saw systems for recording and acting on safety alerts required strengthening. At this assessment there were systems to receive and respond to medicine and safety alerts, however this required further improvements. We saw the practice maintained a log of all alerts, which included the completion of any identified actions and staff responsibilities. We saw that the system had been strengthened and a sign sheet was now available for staff to confirm acknowledgement of alerts. Our clinical searches looked for patients who may have been affected by safety alerts or medicines alerts published in the past. We found that there were issues, for example annual risk assessments were not always in place; there was not always evidence to confirm contraception advice; nor the risk associated with the prescribed medicines had been discussed. There was no evidence of patient harm. Following our assessment, the practice took immediate action to further investigate and follow up these patients. We found that strengthening was required to identify patients who may need a steroid alert card in line with national guidance. Following the assessment the provider informed us of their plans for patient safety alerts to be prioritised in annual audits. Our clinical searches reviewed 5 records for patients who had more than 2 issues of steroids in the last 12 months and identified 4 patients who had not been issued with a steroid card in line with national guidance. There was no evidence of patient harm. Following our assessment, the practice took immediate action to investigate and follow up these patients and an action plan put place to further strengthen monitoring systems. The provider had processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Learning from incidents and complaints resulted in changes

Feedback from one person using the service raised concerns with safe systems pathways and transitions undertaken through a referral pathway. The provider had taken action to learn and improve in line with the practice complaints policy.

The providers information sharing agreement described the process of sharing information with external organisations and the reasons for this. For example, to investigate complaints, potential legal claims, protect children and adults at risk, assess needs, service delivery and treatment. The provider had systems to ensure fair processing and privacy., These detailed to the public how information may be used, for example to support the management of patient records, communicating concerns regarding clinical, social, and supported care, to ensure best outcomes, health, and social research and to support clinical planning. Staff who undertook referrals to secondary care understood systems and processes in place to minimise any potential delays. Staff had knowledge and understanding of local referral processes and arrangements. The practice safety netted by advising patients to telephone the GP and the administrative team if they had not heard back regarding their referral within the expected timeframe. The provider shared significant events from the last 12 months and told us no events relating to referrals processes had been reported. We spoke with staff during the assessment who confirmed there were effective systems to manage tasks. Staff confirmed tasks were overall managed on the day and there was a system to remind staff of outstanding tasks. Staff were able to describe the practice workflow documentation management system.

Healthwatch told us they had not received concerns or feedback from people using the service in the last 12 months.

Administrative staff had systems in place to ensure accuracy in documentation and workflow processing and the management of urgent pathology results. At the previous inspection we identified improvements were required in the management of people living with hypothyroidism who had not had their thyroid function tests completed within the last 18 months. At this assessment we undertook clinical searches for patients diagnosed with a long term conditions, we identified 154 patients with hypothyroidism, and noted that only 2 patients had not had a thyroid function test within the last 18 months. We did not undertake any further analysis of the 2 patients identified as there were assurances in the numbers identified. We reviewed the management of test results as part of a review of patients with diabetes whose latest HbA1c was more than 75mmmol; this is a blood test that shows the average level of blood sugar (glucose) over a period of time. Overall, the findings were positive, we identified one patient who required urgent action. During the assessment, the provider confirmed that this patient had been recalled and action taken. No patient harm had been identified. At the previous inspection there was an ineffective approach to the documentation management of test results and there clinical oversight of test results required improvement. There was now appropriate clinical oversight of test results, including when reviewed by non-clinical staff. Previously, the practice did not have an effective system in place to recall patients who required blood tests. At this assessment commissioners shared the providers action plan following the last inspection, it identified changes had been made to the system of responsibility to monitor blood tests and that this was now assigned to clinical staff. The provider had introduced a correspondence management policy, which included descriptions of clinical coding actions required for test results and actions required.

Feedback from patients raised no concerns about safeguarding.

Staff were able to identify the safeguarding lead during our assessment. Twelve members of staff submitted staff feedback which detailed their level of safeguarding training. Staff described their individual roles in ensuring patients, including vulnerable and children, were followed up if they failed to attend appointments. Leaders we spoke with described how the practice monitored and maintained oversight of safeguarding training and processes. Alerts were placed on the practice clinical system for patients at risk, and the practice had a register to monitor and action concerns about patients. There were systems to follow up children who were not brought to their appointments. Leaders told us safeguarding concerns were discussed regularly as a standing agenda item, and as a small practice any concerns would also be discussed immediately. We saw evidence of practice meetings where safeguarding concerns were discussed. Leaders told us there had not been any recent safeguarding concerns. Leaders for safeguarding confirmed no patients had been identified at risk of female genital mutilation (FGM) At the previous inspection multi-disciplinary meetings (MDT) had been paused during the COVID-19 pandemic and had not restarted. At this assessment leaders described ongoing difficulties in reinvigorating these meetings. Leaders confirmed this was a locality wide issue and meetings would be reinstated in the future. We saw evidence that the practice was working with local practices to relaunch end of life MDT meetings with the local hospice. Leaders told us Deprivation of Liberty applications were made when required. The social prescriber worked with the practice manager to review potential safeguarding concerns, in particular in relation to welfare and financial support.

We did not receive any concerns from commissioners or other system partners about safeguarding systems and processes.

All staff employed directly at the practice had completed training at the appropriate level of their role. During the assessment we identified that not all staff employed through the Primary Care Networks (PCN) had been trained to the appropriate level for their role, and staff were not aware of this requirement. During the assessment, the provider gave assurances that all PCN staff had been contacted to advise them to complete all required training specific to their role. The provider shared their safeguarding child and adult policy as part of the inspection, we found that the policy had not been reviewed and updated to reflect the correct safeguarding leads. During the assessment leaders shared an updated policy which reflected the correct deputy lead for safeguarding. Leads roles and contacts were displayed in every consultation room and reception area. Safeguarding was a standard agenda item at practice meetings and incidents of concerns observed by staff were discussed. Leaders led discussions and learning from safeguarding incidents. We reviewed 4 staff files and found that appropriate DBS checks had been completed. Chaperone processes were in place, and we saw chaperone posters displayed in clinical and reception areas.

The provider shared feedback collected from people through the Friends and Family test over the period of January - June 2024. Feedback was positive overall, and people did not raise concerns in their involvement with the provider to manage identified health risks.

Staff told us there were systems to schedule appointments for patients with long-term conditions, immunisations, and screening/investigative tests. We were told children, or vulnerable individuals, who were not brought or did not attend appointments, were flagged to leaders and management for follow up.

The provider had a reception triage policy in place (June 2024) which identified a range of symptoms and condition which may require urgent clinical intervention, for example Sepsis. Staff had received training and guidance to recognise patients who were acutely unwell (including sepsis). We saw guidance/posters available around the practice to support people to recognise sign and symptoms. We found there were adequate systems to assess, monitor and manage risks to patient safety. For example, there were systems and processes to ensure enough staff to provide appointments and prevent staff from working excessive hours. The practice had policies to ensure patient data was securely stored and managed safely, this included staff smartcard use.

Leaders told us they ensured health and safety risk assessments were conducted and appropriate action taken. Staff we spoke with told us there were health and safety procedures and they had completed relevant health and safety training, including fire. They also described recent fire drills and knew what to do in an emergency or major incident.

We looked at the practice documentation relating to health and safety during our assessment. We saw a range of activities had been completed. We carried out checks within a clinic room to confirm the practice maintained appropriate equipment availability and safety, medicines storage, and waste management. However, during the onsite assessment we identified that emergency medicines and equipment management storage required improvements. Leaders took immediate action during the assessment to improve the availability of equipment and medicines to respond effectively to medical emergencies.

A fire risk assessment had been conducted on 30/04/2024 by the practice manager. An action had been identified to ensure a floor plan was displayed within the practice to support the fire evacuation procedure. During the onsite assessment we did not see the floor plan displayed. Leaders were able to locate a copy of the floor plan however this had not been displayed in the building. Following the inspection the practice team provided assurances that the floor plan had been updated and displayed within the premises. Staff told us that COSHH procedures were in place, and no COSHH products were kept on site. We asked staff what would happen if they were required to clean an area following an incident in the reception area, for example vomit, they told us spillage kits were available. Health and safety, and fire risk assessments were conducted by the practice. Remedial actions were being monitored and completed. We saw the practice had a range of policies and protocols available to staff regarding safety arrangements. All documentation was recorded centrally on their document management system. Business continuity plans were in place, including responding to extreme weather events.

The provider shared their family and friends records from January - June 2024, however we did not see any evidence that the provider had analysed this information. No data was available on the national friends and family data set. Information contained within the data shared demonstrated that overall people had responded positively about their experiences of the service.

We were assured that there were processes in place to monitor and action internal staff training needs. However, we saw gaps in mandatory training, for example safeguarding training, for staff employed by the Primary Care Network (PCN) and working within the practice, this included clinical pharmacists. During feedback we raised safeguarding training levels as an area for improvement and immediate action; immediately following the assessment leaders provided assurances. As the last inspection in May 2022, we did not see any documents to assure us there was appropriate clinical oversight for the Advanced Nurse Practitioner (ANP) and we did not see that the ANP had completed all mandatory training. At this assessment we found that the previous Advanced Nurse Practitioner (ANP) had left the practice and the practice had successfully recruited to the post in March 2024. We saw that they had completed mandatory training in line with the practice policies, and any gaps identified leaders had requested copies of training external records for assurance. We spoke with them during the onsite inspection, they told us they felt supported by leaders. Leaders told us that clinical supervision was undertaken by the Lead GP; however, we did not see evidence of recorded competency checks. At the last inspection not all staff were aware the practice had a Freedom to Speak Up Guardian. During this assessment leaders told us they fostered a positive culture where people felt they could speak up and their voice be heard. Staff we spoke with confirmed this.

At the last inspection there was no system to record annual professional registration checks were regularly monitored. After the inspection, the provider challenged this and confirmed that visual checks of professional registration and indemnity were made every 12-18 months and clinicians undergo revalidation and annual appraisals, the provider had identified an action to ensure they kept a written record of these checks. The practice had not always conducted complete recruitment checks, we identified inconsistencies and gaps in the recording of information, including induction checks. Leaders received feedback about this issue during the onsite inspection and took immediate action to embed and strengthen recruitment systems in the future. We reviewed 4 staff files, 3 files were for staff who required ongoing monitoring of their registration, we saw that the provider was able to evidence these checks, however there were still improvements needed to improve the consistency of recording this information consistently.

We did not receive any concerns from patients about infection, prevention, and control.

Staff we spoke with were able to tell us who the lead for infection, prevention, and control (IPC) was. Staff were able to tell us about the cleaning schedule at the practice. The IPC lead had recently undergone additional training for their role. They described processes to ensure handwashing was conducted in line with IPC standards but were unable to describe other examples of infection control issues within the practice environment. They were new to the role and their experience was limited. They were being supported by the local commissioning IPC team, however at the time of the assessment they had not taken up the offer of training and support. Leaders told us an IPC support visit was planned with commissioners the week following the assessment and evidence from the audit was shared following the assessment.

We observed overall the practice to be clean and tidy throughout. The reception area was clean and tidy, we saw that people had access to antibacterial wipes to clean equipment, for example the blood pressure machine. All clinical areas had wipe clean floors and no carpet was observed. We did note dust on some surfaces in one clinical room and there was water damage on the ceiling in the reception area. Leaders told us there was no COSHH cleaning cupboard onsite and all cleaning equipment was brought onsite by the cleaning contractors. We were told that spillage kits were available if required at reception, this was not in line with The National Standards of healthcare cleanliness 2021.

Annual audits were completed, alongside monthly audits. An action plan was also produced following these audits. The practice had a safe water policy and legionella testing was completed. There was a process in place to record accidents and incidents relating to infection, prevention, and control. All staff had completed IPC training in line with the practice policy. Staff had access to personal protective equipment (PPE). Following the assessment the practice shared an IPC audit undertake by commissioners, this identified a number of areas for improvement, including improvements needed within examination rooms, public toilet and waiting room areas.

The practice had received 4 complaints in the last 12 months. One complaint related to medicines prescription management. The provider had taken appropriate action and identified training for staff and apology given.

Staff and leaders told us they had systems and processes in place to support the safe prescribing of medicines. The practice employed 2 clinical pharmacists and 3 pharmacy technicians, through the Primary Care Network (PCN) who supported the GPs in the practice. Prescribing and medicines management were discussed regularly at clinical meetings. Following our clinical searches the practice updated some of its policies and processes to improve results for patients. We spoke with 2 members of the pharmacy team at the practice, this included the lead pharmacist and pharmacy technician. The lead pharmacist confirmed they were not an independent prescriber but had plans to undertake professional development in the future to undertake this role. Feedback was overall positive, and no concerns raised. At the last inspection there were ineffective systems in place to ensure patients prescribed repeat medicines had received regular, appropriate, and comprehensive structured medicines reviews. After the inspection, the provider challenged this point and confirmed that structured reviews were undertaken and described plans to adjust the approach so that patients due a medicine review who are not would be offered an appropriate appointment. During the interview, the team were able to describe the process for booking medicine reviews and assurances were noted which included a programme of 3-to-6-month audits to identify patients.

The provider had shared details of a significant event, where there had been an exposure of vaccines to light or temperature outside the recommended range , before the onsite assessment. During the onsite assessment we reviewed the fridge temperature log and noted that on the day of the cold chain breach the entry was blank. This was the only date entry that had not been completed in the temperature log. Immediately after the assessment the practice confirmed changes had been implemented to improve the effectiveness of reporting future incidents to all staff for learning. The practice had undertaken a cold chain audit to provide assurances. During our checks we found that all medicines were stored securely. Vaccines were ordered and stored in accordance with national guidelines. The practice had a system in place to monitor the appropriateness of non-medical prescribers, however this required improvements. During the onsite assessment we found that practice did not always have up-to-date Patient Group Directions (PGDs) in place for staff carrying out specific vaccinations. We identified 8 PGDs were invalid and signed by an individual who no longer worked at the practice. Leaders took immediate action and all the identified PGDs were reviewed and updated. The practice shared learning from the event to mitigate the risk of any future PGDs being invalid.

At the last inspection systems for the appropriate and safe use of medicines including medicine optimisation were ineffective. At this assessment, the practice had undertaken an audit to ensure patients prescribed controlled drugs were being monitored in line with local and national guidance. At the last inspection emergency medicines and risk assessments were not always appropriate and in line with national guidance. At this assessment, the practice had an emergency drug monitoring and risk assessment policy in place. This identified items not stocked in the emergency box and a risk assessment had been completed and monitored for these items. However, one medicine recommended was not included and there was no evidence of a risk assessment in place for this. Equipment was not located in one central area, which may lead to potential delays in an emergency, for example oxygen masks for adults and paediatrics were not located with the oxygen cylinder. Immediately after the inspection the provider acted and provided assurances. The practice had processes in place to ensure vaccines were appropriately stored, monitored, and transported in line with national guidance. The practice had reported and acted following a cold chain breach. The practice had continued to monitor and prescribe hypnotics medicines in line with NICE guidance. Processes to monitor and prescribe broad spectrum antibiotic were effective. Appropriate antibiotics prescribing helps to reduce the spread of antibiotic resistance.

At the last inspection not all patients prescribed repeat medicines had received a timely structured medicines review. This included patients who were prescribed controlled drugs (medicines which can cause harm if they are not used properly and can lead to dependence and misuse). At this assessment, the provider had completed a Gabapentin audit in May 2024 and undertaken activity to monitor patients identified. At the last inspection, the process for monitoring patients' health and the use of medicines including high risk medicines with appropriate monitoring and clinical review prior to prescribing required improvement. We reviewed the number of patients prescribed Azathioprine and the number of patients who had not had the required monitoring in the last 6 months. We found blood test results were not always located within the patient medical record. For continuity of care and assessment of safety when prescribing other drugs, the practice results should be available in the record. Leaders confirmed the processing of blood tests was undertaken an external organisation. Leaders confirmed that staff had access to view the blood results. During the assessment, the lead GP spoke with the provider who confirmed that blood tests were reviewed and actioned appropriately. The practice confirmed they had taken action to copy the results into the patient records. Leaders confirmed arrangements in place had been led by local commissioners and that action had been taken to review all the patients identified. No harm had been identified.