Pudding Pie Lane 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 assessed 2 quality statements in the safe key question. We found areas of good practice but also identified areas for improvement. Staff told us there was a culture of safety and learning. The practice had a system to allow people to speak up when they had concerns and staff told us they would be confident to do so and that action would be taken. Staff told us there was a culture of safety and learning. However, found significant shortfalls with how the practice manages medicines optimisation (ensuring people get the right choice of medication suitable to their health need and are engaged in the process).

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.

We received feedback from local residential care homes where some of the patients live. They told us the practice was very responsive to meeting the needs and preferences of their residents and to requests when changes to people’s medicines was required.

Staff who were affected were involved in investigating significant events and complaints and identifying learning. Learning was shared with those that had been involved with an incident. Staff told us they felt they were able to raise concerns and report when things went wrong. Leaders told us they shared learning in whole practice meetings, clinical meetings and this is reviewed by partners. However, staff also told us their experience was that learning was not consistently shared further across the practice. They felt there could be an improvement in communication from leaders regarding how important information and decisions were shared across multiple sites. Staff and leaders were able to share examples of incidents and complaints which had been investigated and the actions they had identified.

The practice had policies and procedures in place to support the learning culture. The practice offered apologies to people when things went wrong, lessons were learnt from individual concerns and complaints and action was taken as a result to improve the quality of care. We reviewed a complaint and saw that action was taken in the form of a teaching session for staff. We also saw evidence learning was identified and shared with staff. Complaints and significant events were reviewed on a quarterly basis to identify trends and review learning that had taken place. Dispensing incidents and near misses were recorded and reviewed regularly to identify themes and reduce the chance of reoccurrence.

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.

Results of the national GP Patient Survey indicated patients were involved as much as they wanted to be in decisions about their care and treatment during their last GP appointment.

Staff and leaders told us they had systems and processes in place to support the safe prescribing of medicines. Leaders told us they had met nationally set targets and we saw an example of this for prescribing of antibiotics. We spoke to staff who explained the policy around the cold chain process ( a way of ensuring vaccines are transported and stored safely). Staff and leaders told us they met regularly to review their prescribing, and the management of patients receiving high risk medicines and medicines which require monitoring.

The practice held emergency equipment and emergency medicines at the main practice and branch sites and they were checked on a regular basis. However, we found the practice did not stock all appropriate emergency medicines. During the inspection, we asked to see the emergency medicines risk assessment which did not address the risks of not stocking the recommended medicines. Following our onsite visit, the practice sent us a further risk assessment for medicines that they either did not store with their emergency medicines or did not stock. Policies relating to prescription stationary had been recently updated but processes were not yet fully embedded. Medicines stock was appropriately managed and expired medication was safely disposed of, and appropriate records maintained. We viewed a sample of Patient Group Directions (a written instruction for the supply and administration of a licensed medicine to a group of patients). They were authorised by a qualified prescriber such as a doctor and followed by non-prescribers.

There were arrangements for raising concerns around controlled drugs with the appropriate professional bodies. Vaccines were stored, monitored and transported in line with UKHSA guidance. There was a High Risk Drugs Monitoring Policy however, it did not contain information on what to do if a patient did not engage in monitoring. We found 44 of 169 patients prescribed Aldosterone antagonists (potassium sparing diuretics) overdue monitoring placing them at risk. We reviewed 5 patient records and found 1 had stopped the medicine mitigating their risk but the other 4 were overdue monitoring. The practice had access to an external patient reporting system which demonstrated monitoring had taken place. During the onsite visit, the practice were in the process of manually uploading monitoring results to patient records. Monitoring for 18 patients had taken place and for the remaining 26, results were being sought. This meant at the time of inspection, the practice had not recorded monitoring had taken place before prescribing, meaning a potential risk of incorrectly prescribing. Medicines safety alerts were actioned and disseminated across the practice and evidence of actions recoded. However, we saw evidence historical alerts were not actioned at the practice. We found 30 patients co-prescribed clopidogrel with omeprazole or esomeprazole (taken together can alter their effectiveness). The Medicines Healthcare products and Regulatory Agency issued an alert regarding clinical interaction risk of these medicines which should be discouraged. The practice told us they acted when they first received this alert but had not reviewed it since. Following the onsite visit, the practice told us they had reviewed historic safety alerts and implemented a regular review process. The practice had a dispensary and a GP was responsible for providing effective leadership. Dispensers could speak confidentially to patients and protocols described the process for referral to clinicians.

We reviewed prescribing data available to us and found the practice was prescribing within the expected ranges. The practice had clear Standard Operating Procedures which covered all aspects of the dispensing process, were regularly reviewed, and a system was in place to monitor staff compliance.