Dr C D Lenton & Partners Also known as Ashfield 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 carried out an announced assessment of 6 quality statements (Learning culture, Involving people to manage risks, Safe environments, Safe and effective staffing, Infection prevention and control and Medicines optimisation) under the safe key question and found: Leaders had implemented systems and processes to ensure safety, however, not all processes were fully effective or fully embedded. When people raised concerns about safety and ideas to improve, solutions to risks are not always developed collaboratively or in a timely manner. Patients were supported to make choices that balanced risks of harm with positive choices about their lives. However, leaders did not always ensure there were enough skilled people to deliver safe care that promoted choice, control and individual wellbeing.

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.

CQC had received feedback from 3 people that related to the management of their complaint to the practice. We found that one complaint was handled appropriately and practice staff had met with the person to discuss their concerns. The other feedback we received was negative and included that the person did not receive a response from the practice or that they were not able to speak with the manager to discuss their concerns. From the NHS UK website we found 23 reviews had been left by people between March 2023 and February 2024. While there was no feedback left about the management of complaints, we found that responses (positive or negative) were not always replied to by the practice in a timely manner. However, when the practice did reply they were open and honest with people. The practice website contained information on how to complain and at the time of the assessment there was no information displayed in the waiting area about the complaints process or what improvements had been taken following patient feedback. Leaders told us at the time of the assessment the practice with the support of the patient participation group (PPG) was updating information in the practice waiting area; this included information for patients on the practice’s complaint process. The PPG were kept informed about improvements the practice were planning to improve the quality of services provided.

Staff told us that when patients wanted to speak with staff about their complaint, relevant staff were not always available. This meant that patients had to submit their complaint in writing and could not verbally discuss their complaint and have it resolved in real time. Leaders told us a new staff role had been created, a complaints handler administrator, to help deal with complaints and resolve minor complaints in real time. Staff we spoke with were not aware of this role. Leaders sent us evidence, following the assessment, that showed written communication about this role had been shared with staff during the assessment. Staff were kept informed about incidents and subsequent learning, particularly if it impacted on their role. However, they were not made aware of all complaints that came into the practice or any subsequent learning. Staff told us that communication could be improved to aid learning following incidents and complaints. The practice was not having regular staff meetings. When meetings were held, if staff could not attend, meeting minutes were not shared with them. Leaders sent us evidence, following the assessment, that showed meeting minutes were emailed to staff. The provider should review their processes to ensure that communication is effective. Leaders told us they were aware they needed to improve communication within the practice. They intended to start whole practice meetings where a representative from each team would attend, and then they would feedback to their teams. Staff told us they had opportunities to share concerns or ideas for improvement, but did not always feel listened to. They did not always receive feedback or an update on the concerns they had raised. Staff we spoke with were not aware of who the Freedom to Speak Up Guardian was; however, they told us they had someone within the practice they could speak to. Not all clinical staff felt they had time or opportunity to discuss concerns as a team, to learn from one another.

The practice had an appropriate complaints policy. However, the policy had not been updated since August 2023 to include details of the complaints handler administrator role. Written complaints we viewed were handled in line with the policy. The practice was open with patients if mistakes had occurred and if there was any learning for staff. The practice had received 16 complaints between April 2023 and April 2024. The practice had identified a trend in patients complaining about appointment access or availability and had acted to improve appointment access. Following concerns from patients and staff about travel vaccination, the practice had improved the travel vaccination policy. There were no whole practice meetings and even though we saw there had been meetings for the nursing team during January and February 2024, there had been no discussion of complaints or incidents/significant events. Processes to report and manage significant events were not effective or well embedded. The significant event policy, although reviewed in February 2024, lacked detail and relevant information that would allow the effective management of significant events, incidents and near misses. The policy did not state when and by whom trends in significant events were analysed. The policy said that findings should be discussed in clinical and non-clinical meetings. However, the practice were not having non-clinical meetings, and there was no evidence in the nurse’s meeting minutes we viewed of any discussions about incidents or significant events. Leaders were updated about incidents and complaints however there was no evidence of trends analysis. Staff had reported 11 significant events between May 2023 and April 2024. During the assessment we found other examples of incidents and near misses that should have been reported as a significant event, however they were not, meaning missed opportunities for learning and improvement.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

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

The 2023 GP patient survey data showed that patient satisfaction with being involved in decisions about their care and treatment remained high. Of the people that responded to this question, 93% responded that during their last GP appointment they were involved as much as they wanted to be in decisions about their care and treatment. The PPG were kept informed about issues affecting the practice; this included concerns that would have a direct impact on care delivery. We viewed a sample, at random, of five care records for patients with COPD and saw that people with COPD were involved in their care plans. We reviewed a sample, at random, of 5 care records for patients that had received minor surgery at the practice. We found that consent was sought appropriately before minor surgery was performed, with risks and benefits explained and patients given appropriate aftercare advice.

Patients are informed about any risks and how to keep themselves safe. Staff would use alternative methods of communication where needed, for example GPs used drawings to help explain minor surgery procedures. Risks are assessed, and patients and staff understood them. Staff told us there was a balanced and proportionate approach to risk that supported patients and respected the choices they made about their care.

The practice carried out minor surgery audits each year to monitor that consent taking processes were being followed according to their policy. From audit information we viewed, we saw that 49 out of 50 patients had documented consent in their care records in 2023, and all 50 patients had documented consent in 2022. The practice monitored patient satisfaction and were aware of the 2023 GP patient survey results. They took action to improve when patient satisfaction was poor.

Staff told us the practice completed risk assessments and these were audited monthly.

The facilities and premises were appropriate for the services delivered and were mostly well maintained and equipped to support timely diagnosis and treatment of patients. The practice was located within purpose-built premises. Patients had access to consulting rooms on both the ground and first floor. During our observation of the practice premises, we found equipment was not always stored safely. We saw that a wheelchair was stored in the electrical cupboard and cleaning equipment, safety signs and a ladder were stored in the boiler room. The practice told us, following the assessment that they were not aware of any regulations preventing this, however they did not submit any further evidence to demonstrate that this equipment was stored safely. We also found that the practice was not visibly clean in some areas including by the fire exit which had not been cleaned and cobwebs were seen. The practice told us that this area was not accessed by staff or patients.

Reasonable adjustments had been made so that people in vulnerable circumstances could access and use the services. There were disabled toilet facilities and baby changing facilities. There was a hearing loop available for those with a hearing impairment. The practice had processes in place to test electrical equipment to ensure its safe use. We saw the practice had completed risk assessments to assess, mitigate and monitor safety issues related to the premises. However, processes were not fully effective in identifying all safety concerns, including those that we identified during our assessment.

CQC had received 2 complaints about not having considerate support delivered by competent people. In particular patients had concerns about how their requests for appointments were being triaged and managed. Leaders told us the process for triaging was being improved.

Non-clinical staff told us they did not always have a comprehensive formal induction program; they told us learning was while they carried out the job and not in an organised and structured way. Staff reported, as a result, errors were made for example in the allocation of appointments. Leaders told us induction training was provided for all staff. Not all staff we spoke with knew what to do in the event of an emergency. Staff told us they did not have time for required training during working hours. Staff did not always feel supported by their direct line manager. Staff told us they had not received training on sepsis or triaging appointment requests. Leaders sent us evidence to show, at the time of the assessment most non-clinical staff had completed health navigation training and sepsis awareness training. However, we saw that for 7 other staff Sepsis training had expired. Clinical staff told us they had support from the GPs when they needed it and felt supported by leaders to undertake development and meet the requirements of professional revalidation. Staff told us there was not enough nursing staff, either because of staff sickness or following staff reducing their hours and these hours not being replaced. This meant they did not have allocated time for non-clinical duties and patients had longer waiting times for a nurse appointment. Staff told us they worked within their competences. Leaders sent us evidence to show that all lost nursing hours since 2021 had been replaced in 2024 with a newly qualified nurse.

We reviewed the recruitment files for 6 members of staff, both clinical and non-clinical. We found there were gaps in the information the practice held about staff. This included proof of identity and full employment history. Leaders told us they were addressing this as part of the wider organisation review of staff files, which included digitalisation of the records to ensure documentation and information held was complete and accurate. We also found that staff files did not always include information on the immunisation status of staff. Records for newly recruited clinical staff included information on induction they had received. From files we viewed we saw that staff had completed training identified as mandatory by the provider. Clinical staff had opportunities to attend local networks and online events to help maintain skills and development.

There was one negative review on the NHS website from a person not being able to make an appointment for travel vaccines. The person had followed the practice’s process and given sufficient notice. We saw the practice had replied, and had been honest about staff sickness and the impact this was having on appointment availability. There was another review about a person not being able to book their COVID19/flu vaccine. The practice had replied. The NHS website included one positive comment about the surgery being clean and comfortable.

Leaders told us that they carried out infection and prevention control audits and used an internally developed audit tool. Some staff felt that audits were not adequately identifying risks or that appropriate action was not always taken. Staff also expressed concern that the lead for infection prevention and control had not received adequate training for the role.

We found that the practice was generally visibly clean; however, there was a build-up of cobwebs on a security door located at the back of the building. The door was not in use and had been sealed off.

The practice did not have effective processes in place to appropriately manage infection prevention and control. The practice had an infection policy and procedure in place which was easily accessible to all staff. The practice had a lead for infection and prevention control. We saw the lead had completed training as required by the provider’s policy. However, the lead had not completed additional training that would have supported them further in this role. The practice had contracted external cleaners to clean the premises and a cleaning rota had been developed. However, the cleaning rota did not detail when and if high level cleaning would be carried out. The practice could not demonstrate that the outcome of infection control audits was disseminated and shared with staff to ensure appropriate action was taken. Monthly audits showed that the same incidents were repeatedly identified. There was no evidence that action had been taken to address these and prevent them reoccurring.

CQC had received 2 complaints from people about the management of their medicines. Complaints included that people experienced delays in getting their repeat prescriptions because they could not always get an appointment when they needed it to review their care. Or when appointments were given, communication was not clear and staff were not informed about changes to medicines or why they were needed. During our assessment we looked at one of these complaints in detail and found that staff acted safely, and although there were delays in care, there was no harm caused. However, poor communication between staff led to a poorer patient experience.

If a patient requested a repeat prescription and their medication review was overdue, non-clinical staff were alerted to this on the system. Staff reminded patients to book an appointment and also sent a task to the GP. Non-clinical staff worked through prescription requests each day and told us there was no backlog in processing prescription requests. Leaders were aware that appointment availability was impacting on patients’ ability to attend the practice to provide information that was required for safe repeat prescribing, so where appropriate they were trying to find different ways to collect this information. For example, leaders told us that if information was required from people, before a prescription was issued, if appropriate, they could request this by text message from patients, instead of asking them to make an appointment. Leaders were aware there was a backlog in medication reviews and that the overall management of medication reviews needed to improve. Leaders told us that there were dedicated staff assigned to working through the backlog. They also told us they had found coding issues in patients’ records where medication reviews had been done, however records were not coded correctly. A search had been done to identify which records needed amending. However, there was no clear plan on who would be re-coding the records and by which date. Leaders told us they treated patients as individuals and had processes in place to risk assess each patient’s needs and circumstances and offer treatment accordingly.

We found that medicines were stored within designated cupboards and fridges. However, we identified concerns with the monitoring of stored medicines at the practice. For example, we found one medicine that was past its expiry date and had expired in October 2023. Emergency medicines and equipment were not easily accessible. For example, medicines and equipment were stored in different areas in one of the consulting rooms and the oxygen cylinder in its case was stored behind a desk. An arrow indicated to staff where the cylinder was kept but it was not easy to access in an emergency. Other (non-emergency) items were stored in the emergency medicine box which further restricted ease of access to its contents. We found that the expiry dates and batch numbers on the boxes in which the medicines had been dispensed had been cut off or blurred by writing over them.

The practice had a medicines management policy however, there was no information to say when the policy was implemented or when it was last reviewed. The policy said that medication reviews should be carried out at least annually or, in cases of complex repeat prescriptions, every six months. At the time of our assessment, the practice did not have an effective process in place to monitor that every patient that required a medication review had received one. There were 495 patients on multiple medicines waiting for a medication review. The staff responsible for completing these reviews were doing approximately 10 reviews a week, this meant it would take approximately 50 weeks to work through the backlog. Staff told us some medication reviews were carried out as part of a patient’s routine appointment. Other reviews were done reactively when a patient’s prescription was due. Leaders were aware this process needed to improve and were thinking about more effective ways in which to carry out medication reviews. Patients could request a repeat prescription using different methods. Patients could use the letter box at the practice, through the website, using post, through their local pharmacy or if housebound the patient could call the practice or request through their pharmacy. At the time of the assessment the process for dealing with an urgent prescription request was being reviewed and improved. However, had not yet been implemented. The practice did not have effective processes in place to store and monitor medicines that were kept at the practice. Controlled medicines were not stored at the practice. Arrangements were in place for raising concerns relating to this group of medicines.

During our assessment, we selected 20 patient records, at random, to review the care of patients with a mental health diagnosis, COPD or those requiring a repeat prescription. Our review indicated that 19 out of 20 of these patients had received effective medication reviews. One patient had not had a formal medication review since 2021. However, they had been seen regularly by clinicians and we found no concerns with the overall management of their care. Non-clinical staff had identified that for some patients, their nominated pharmacy for collecting prescriptions from was being changed without the patient’s consent. To improve patient experience, when staff processed prescriptions requests they checked that pharmacy details matched the patient’s preference. If there were any concerns they called the patient to double check their preference. This meant patients were attending the correct pharmacy to collect their prescription and there were no delays in them taking their medicines.