Ferryview Health Centre GP Surgery

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• 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 looked for evidence that people were protected from abuse and avoidable harm. At our last inspection in 2019 we rated this key question as good. At this assessment, the rating has changed to requires improvement. There was a good learning culture at the practice and staff were able to raise concerns. However, we also found that the practice did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. The provider was in breach of legal regulation in relation to safe care and treatment.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice had a proactive and positive culture of safety, based on openness and honesty. Senior leaders and staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. All of the staff we spoke to were aware of how to raise incidents. Staff we spoke to detailed how learning from incidents was shared with them on both an individual basis, and organisation wide. Leaders detailed how they supported the process, and staff as required.

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.

The practice had a safeguarding lead, who was one of the partners at the practice. There was also a deputy lead, who was one of the practice nurses, and an administrative lead. Staff were aware of how to make safeguarding referrals, and knew the identity of the leads if further advice was needed. The provider carried out the required checks when recruiting staff. The provider worked with other agencies to support patients and protect them from neglect and abuse. Staff took steps to protect patients from abuse, neglect, harassment, discrimination and breaches of their dignity and respect. The practice had a safeguarding register of both children and vulnerable adults.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

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

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

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

We reviewed 5 patients prescribed an immunosuppressant (a type of medicine used to calm or control the body’s immune system). We found that 1 patient was overdue the necessary monitoring tests for this medicine. We reviewed 5 patients prescribed a medicine used to treat mood disorders. We found that 3 patients were overdue monitoring tests. The provider had not taken action on all patient safety alerts. We reviewed 5 patients prescribed a combination of medicines which were subject to a safety alert. Patients prescribed these medicines should receive monitoring tests as there are a number of potential side effects, including kidney impairment and over or under active thyroid levels. We found that 3 of the patients reviewed were overdue monitoring tests. We reviewed 5 medication reviews. We found 2 reviews contained insufficient information, therefore it was unclear whether a sufficient review had taken place. We reviewed 5 patients identified as having a potential missed diagnosis of chronic kidney disease (CKD) stage 3, 4 or 5. We found 2 patients had a missed diagnosis of CKD, meaning these patients may not receive the regular monitoring required for patients with CKD. Another patient was overdue a repeat test. We reviewed 5 patients prescribed a medicine to treat epilepsy and nerve pain. We found 4 patients were overdue monitoring tests. Three of these patients were also overdue a medication review. Three patients were overdue a review of the dosage of the medicine, which was particularly important as this medicine can be addictive. We did not see evidence that 1 patient had been advised of pregnancy associated risks. The provider did not hold either atropine or an antiemetic in their emergency medicines. Atropine is required where contraceptive coils are inserted or removed. Leaders at the practice had not formally risk assessed the absence of either medicine.