Kingskerswell and Ipplepen Medical Practice Also known as Dr D'Arcy & Partners

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 have rated the practice as Good for providing safe services because: The practice had a culture of reporting and investigating incidents and significant events. Learning from the investigations was shared with staff and systems and processes reviewed and developed to improve services. There were systems and processes to monitor patients prescribed medicines which required additional monitoring. Whilst our clinical searches found gaps in the monitoring, the practice had addressed these and took immediate action to develop systems to prevent these risks reoccurring.

This service scored 84 (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.

Managers encouraged staff to raise concerns when things went wrong and staff told us they felt supported and listened to. All staff were invited to staff meetings where learning was shared. Minutes of the staff meetings were available to staff unable to attend and staff knew where to access these. Staff felt there was an open culture, and that safety was a top priority.

The practice had a system to monitor significant events. Meetings were held monthly with the wider staff teams to discuss events, review learning and discuss improvements. In addition to this process, we saw there was a system to monitor incidents. This included undertaking an investigation into the cause and actions identified to address concerns. The practice had a system in place for the auditing of systems and processes. Audits conducted identified areas of concern, actions taken and provided a clear audit trail to demonstrate continuous improvement. The practice had a system to manage medicines safety alerts from the Medicines and Healthcare products Regulatory Agency (MHRA). The prescribing lead ensures alerts are disseminated to clinicians and dispensing staff, to ensure alerts are actioned.

People who lived in care homes received regular consultations, by telephone, video or face to face with a clinician. This provided continuity of care from clinicians. People who required a referral to secondary care providers were informed of the process for this and provided with information regarding timescales and safety netting. This meant they were aware of the action to take should their condition deteriorate before their appointment.

Staff were knowledgeable about their responsibilities to ensure patient referrals to other services were actioned promptly and within the guidelines set out in their practice policies and procedures.

Feedback from a clinician who worked within a care home commented that the provider was thorough in their approach, worked well with the staff and in the best interests of people living in the home.

The practice had developed systems and processes to ensure patients were referred to other services appropriately. The process for summarisation of records relating to patients newly registered with the practice were up to date, which ensured information was readily available to clinicians. Electronic and paper communications from external services, including discharge letters and feedback from secondary care, were processed promptly, actioned and added to the patient electronic records. The practice had developed a model to provide continuity and proactive care for people who lived in care homes. A named GP had responsibility for the oversight and management of the care of people registered with the practice who lived in the 6 care homes within the practice catchment area. The practice had developed guidelines for care home staff to follow to ensure patients received prompt and appropriate care and treatment. For example, urine sample testing guidance when a patient had a suspected urinary tract infection.

Reviews of patient feedback did not indicate any specific feedback regarding safeguarding within the service.

Staff felt supported when raising safeguarding concerns with the practice safeguarding leads. During safeguarding meetings, the safeguarding leads discussed individual cases and the actions taken to protect individuals. Staff had received appropriate training in line with their roles and responsibilities when identifying concerns. They also felt confident on how to report and act on information.

The practice held multi-disciplinary team meetings (MDT) to share safeguarding concerns with other professionals. This provided assurances that the practice worked with outside agencies to protect and safeguard people who were at risk of abuse.

The practice followed systems and processes to safeguard children and vulnerable adults from abuse and staff knew how to identify and report safeguarding concerns. In addition to this, the practice had implemented policies and procedures which demonstrated partnership working with the other agencies and local safeguarding teams.

Staff were confident in the systems and processes to respond to the risk for a deteriorating patient. We were provided with an example of where such a risk had been managed well by the staff, including reception staff, nurses and GPs, to reach a positive outcome for the patient whereby they had received prompt and effective emergency care. Patients requesting care and treatment through the electronic request form were triaged by a GP to ensure they received priority care when needed.

Staff were knowledgeable regarding identified risks within the practice. Information on how to reduce known risks was included in written risk assessments.

Risks relating to individuals were recorded within their electronic records and the patient record system alerted staff to the risk on opening the record. Emergency medicines and equipment were available and staff were provided with training to use these effectively.

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

The national GP survey demonstrated patients who returned completed questionnaires were satisfied with the staff who provided services to them at the practice. For example, 96% had confidence and trust in the healthcare professional they saw or spoke to during their last appointment, 94% said the healthcare professional they saw or spoke to was good at listening to them during their last appointment and 91% said the healthcare professional they saw or spoke to was good at treating them with care and concern during their last appointment.

Staff told us there had periods when the service was short staffed which meant appointments had not always been available for patients. This had improved over the past few months and additional staff had been recruited to the GP and nursing teams. At the time of the inspection there were 2 vacant administration posts totalling 40 hours per week. These positions were being advertised. However, administrative staff said they experienced periods of not having enough staff to complete work flows. The practice had reviewed the roles and responsibilities of the staff team. For example, a paramedic had been appointed, and carried out home visits and provided triage support to the duty GP to review patient requests for care and treatment. The practice had previously had access to a pharmacist and a pharmacy technician. Following vacancies of these positions a GP was allocated 80 minutes twice a day to undertake all prescription queries. Staff worked well together and supported each other during busy times. For example, the nurses and health care assistants proactively reviewed clinic lists and worked together to ensure the clinics ran smoothly. Staff were positive regarding the training opportunities made available to them. They were able to identify and request funding for external training relevant to their roles and were confident their request would be responded to favourably. Clinical supervision was planned and time booked out in the rota for completion of this. The timescales varied according to the need and experience of the individual staff member. There was not a formalised plan for non clinical staff. However, the provider was aware of this and was able to share their plans for implementing a system and process to support non clinical staff.

The mandatory training requirements had been decided by the partners and management teams and was identifiable on the electronic training system. The system ensured staff were made aware of the mandatory training required for their role and when this was due. Email prompts were sent 4 weeks prior to the training being out of date and daily emails were sent when the training was overdue. Oversight of the training was the responsibility of a manager to ensure all staff kept up to date. Incomplete training was discussed individually with the staff member and plans, including support and time allocation, put in place to ensure this was completed. A review of nursing capacity and demand had been carried out and nursing staff had been recruited. The practice was approved to support trainees to become nurse associates and nurse practitioners. (The nursing associate is a generic nursing role in England that bridges the gap between healthcare support workers and registered nurses, to deliver hands-on, person-centred care as part of a multidisciplinary team). Jobs were advertised internally and externally and all applicants followed a recruitment process. Records including a checklist, were maintained for all staff, to demonstrate the checks which had been made to evidence their suitability for the role. The practice was part of a primary care network made up of several GP practices. This meant the practice had access to additional roles. For example, social prescribers. (Social prescribers help to connect people to activities, groups, and services in their community to meet the practical, social and emotional needs that affect their health and wellbeing). The electronic and telephone systems enabled the practice to monitor and understand workload. This had led to increased staff. For example, a specified role for summarisation of records. The GP partners were supportive to the need for new staff when justified with data and workflow demand.

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.

One patient had left feedback on an external website regarding being unable to order repeat prescriptions. The practice had responded and offered support with the ordering of the prescription. Other patients expressed positive comments about the service provided by the dispensary.

Staff were able to describe the system to identify patients who required monitoring based on the medicines they were prescribed. However, our remote searches of clinical records identified a number of patients had not received appropriate monitoring within recommended timescales. The practice took immediate action and made arrangements for these patients to be reviewed. We spoke with non-medical prescribers ( prescribing clinicians who are not GPs) who told us they were able to discuss their prescribing each day with a duty GP. Staff working in the dispensary told us they felt supported by the medicines manager, and the lead GP who was supportive and approachable.

Cold chain processes were observed at both sites, and we found the recording of fridge temperatures were well documented via an electronic system. Staff were knowledgeable regarding actions to take should the cold chain be compromised. The vaccine fridge at one site was not locked and stored in an unlocked room. This did not ensure the security of medicines. The practice provided assurances this would be addressed immediately. We looked at the emergency medicines and equipment held by the practice and found it was stored securely. Other emergency medical equipment was stored elsewhere in the practice. We found equipment and medicines were monitored to ensure expiration dates did not expire. However, the monthly check list used did not provide evidence that each individual item was being checked, during the monthly audit process. A defibrillator was kept on site, which contained the pads suitable for adults and children under the age of 8 years old. The practice carried out routine checks of the defibrillator to ensure it remained fully operational.

Following our remote clinical searches of patient records the practice reviewed, developed and strengthened their systems to ensure all patients who required monitoring were followed up in a timely way. The practice had a system and policy in place in the management and security of prescription stationary. Prescription security had been compromised in one area at Ipplepen Surgery where a lock to a printer had failed. This was addressed immediately the provider planned to review all of the locks attached to the printers to reduce the risk of this reocurring. Medicines within the practice were managed in a safe way. There was a formal audit carried out regarding non-medical prescribers and their prescribing practices. (Non-medical prescribing is that which is completed by a health professional other than a doctor). Staff had the appropriate authorisations to administer medicines (including Patient Group Directions (PGDs) or Patient Specific Directions (PSDs. 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. PSD’s are an instruction to administer a medicine to a list of individually named patients where each patient on the list has been individually assessed by a prescriber). However, the documentation used to record the PGDs was not being completed correctly in line with guidance from the UK Healthcare protection agency. The practice reviewed this following the on-site assessment and provided evidence which demonstrated these concerns had been addressed. There were policies and systems in place for signing of prescriptions and controlled drug storage, recording and disposal.

Our remote clinical searches identified shortfalls in patient monitoring on certain medications. We reviewed the records of 5 patients with long term conditions - Asthma who have had 2 or more courses of rescue steroids. 2 out of the 5 patients reviewed were identified as overdue for monitoring. 1 out of the 5 patients reviewed for the monitoring of Chronic Kidney Disease Stages 4 or 5 had cause for concern. Required blood tests and BP monitoring was overdue. Hypothyroidism (under active thyroid), 4 out of 5 patients reviewed were identified as overdue for monitoring and this had not been identified by practice. Methotrexate, 1 out of 4 patient records reviewed showed a cause for concern. One patient due a medication review, had not been seen for review and medicines were still prescribed. However, the patient record contained evidence the practice had attempted to contact the patient on several occasions to book a review. Patients prescribed ACE inhibitor or Angiotensin II receptor blocker, 3 out of 5 records reviewed had cause for concern. Medication had been issued despite the required blood tests not being completed and two patients’ records were not coded. Patients prescribed clopidogrel and esomeprazole or omeprazole; 5 out of 5 records reviewed showed a cause for concern. Patients had not been informed of the risks when taking these medicines together. Missed cases of diabetes, of the 5 patients reviewed the records of 3 showed an issue of missed diagnosis of diabetes which included coding and not arranging regular blood tests. The practice took immediate action to ensure all patients registered with the practice prescribed these medicines were contacted if their review was overdue. At the time of the site visit evidence was provided to demonstrate patients had been to the practice or were booked in for monitoring.