Empingham Medical Centre

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 and inspected against two quality statements; Learning culture and Medicines optimisation. During our assessment of this key question, we found incidents were investigated openly and transparently. Actions were recorded and learning was shared with staff to mitigate the future likelihood of incidents reoccurring. Staff were confident in responding to safeguarding concerns and had received training relevant to their role. Systems for the safe management of medicines, including emergency medicines and equipment were in place and regularly reviewed. People received co-ordinated and joined up care when transitioning between healthcare services through the effective management of referrals, correspondence between providers and regularly reviewed local secondary care pathways.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We saw patients felt the provider was receptive to feedback and actioned improvements where they were identified. Ways to provide feedback were advertised at the practice, on the provider website and in a local newspaper. Information on how to make a complaint was available on site and on the provider website.

Staff demonstrated a good understanding of how to report incidents, raise concerns and we saw that there were regular discussions in staff meetings to identify learning. Staff and leaders were able to share examples of incidents and complaints and the appropriate action that had been taken as a result. We saw that leaders used incidents and complaints to improve systems and processes.

The provider monitored and reviewed safety using information from a variety of sources and had clear policies and procedures to support staff to manage this information. There was a system for recording and acting on significant events and safety alerts.

There was a culture of learning, with staff encouraged to report concerns for the whole team to learn. Between December 2023 to November 2024 the practice recorded 19 events that had been investigated and learning shared as appropriate.

The provider had a complaints policy in place and information was accessible to patients in various formats. The complaints we reviewed showed they were recorded and investigated appropriately. Patients received a final response which included details of the process if they wanted to escalate their complaint. Learning from complaints was identified and monitored to completion in a timely manner.

Monthly practice team meetings took place to review all changes as a result of significant events, complaints and updates to guidance. This information was also disseminated to staff through the computer system and other team meetings such as the nurses or reception team.

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.

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.

Patients did not give any comment specifically regarding medicines optimisation.

As part of the assessment, we conducted searches on the practice clinical system and reviewed a selection of patients’ records. We found some improvements were required with monitoring of patients prescribed high risk medicine. For example, there were several patients requiring a medicine to protect their stomach given the other medicines they were already taking, during our searches we found this was not always in place and some patients were at risk. In addition, we found several patients not coded as having chronic kidney disease when recent blood tests confirmed this diagnosis.

The provider acted prior to the on-site inspection and had completed all areas identified in the searches when reviewed during the inspection. In addition, new standard operating procedures had been implemented to ensure ongoing care met the latest guidance.

During our site visit we found storage and management of medicines, including those held on site in case of an emergency, was appropriate. The practice had systems in place to receive, review and act on medicine alerts to ensure clinicians were up to date.

We also reviewed the dispensary and found regulations and guidance was followed and the staff worked closely with the rest of the practice leadership team.

The provider had policies and systems to support management of medicines. There was a process for monitoring patients’ health in relation to the use of medicines including medicines that require monitoring however some issues with the oversight of this were identified. Staff had the appropriate authorisations to administer medicines (including Patient Group Directions or Patient Specific Directions). Staff were up to date with relevant training with regards to medicines management.

A system was in place to monitor stock levels and expiry dates of medicines held on site. Vaccines were appropriately stored, monitored, and transported in line with guidance to ensure they remained safe and effective.

We reviewed clinical records for patients who had been prescribed medicines which required routine monitoring. Our review found some improvements were required to ensure patients had all been monitored and reviewed in line with current clinical guidelines. The practice was responsive and promptly acted on the concerns found through our searches. This included producing an action plan that included a review of medicines management and additional audits planned.

The practice held monthly team meetings which discussed clinical performance, outstanding patient recalls and prescription queries. Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. Prescribing data reviewed as part of our assessment confirmed performance was in line with national averages for various medicine indicators.