Trent View Medical Practice

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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 a total of 8 quality statements from this key question. We have combined the scores for these areas with scores based on the rating from the last inspection, which was Requires Improvement. Our rating for this key question is Good. The service had made improvements and is no longer in breach of regulations. People were now kept safe and safeguarded from abuse. Systems to monitor patients prescribed high risk medicines had been improved but additional oversight was required to ensure these were effectively implemented by all staff. Managers investigated all reported incidents to reduce the likelihood of them happening again however, although staff understood their role, they had not reported all incidents. Staff supported people to live healthy lives and provided them with support and information on their care and treatment.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

One person told us they had not received a response to concerns they had raised. Representatives from the patient participation group (PPG) were able to raise their concerns with the practice but did not always receive a response and were not always involved in or kept informed of improvement actions.

Staff knew how to report and record incidents and confirmed learning from incidents was shared. Actions had been taken in response to an incident relating to security of the practice and the changes had been made in response. However, some staff told us they had not recorded some prescribing and dispensing and referral issues as incidents but had actioned these appropriately. This may limit learning opportunities.

Learning from incidents and complaints resulted in changes that improved care for others. The provider had improved processes for staff to report incidents, near misses and safety events. The policy and procedure for significant incidents included a definition of a significant incident and staff roles and responsibilities. The policy didn’t state how or where a significant incident should be recorded and stored. There was an improved central online system to record incidents, and incidents had been discussed in meetings, actions and learning were mostly recorded. The online system was not yet being used to its full potential to create a full audit trial by linking meeting records and records of actions taken in response to incidents such as new polices and training records. The provider had undertaken a historic review of incidents identified at the August 2022 inspection and detailed investigations had been completed. The provider had improved systems to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Records showed staff took complaints seriously and there were systems to manage and address complaints in the managers absence.

Most patients told us they received good clinical care. Two patients told us how they had been directed to staff with specific clinical skills to provide care and treatment for their condition. However, one patient told us there had been some concerns with the new prescription service when ordering repeat prescriptions as they were not always receiving all the medicines they had ordered. Two people told us they had received text messages which contained incorrect information which had caused them some concern.

Staff had a good knowledge of the processes related to their area of work and actions taken to improve. For example, discharge letters from secondary care were sometimes delayed and staff were liaising with secondary care colleagues to improve the timely management of letters sent to the practice.

No specific comments relating to this area were received from partners.

There were improved systems to manage referrals, pathology results and incoming clinical letters and these were well maintained and up to date. Where incoming clinical letters included information relating to changes in medicines these were tasked to the pharmacy team. The system to manage pathology results in a timely manner included a GP buddy system, and time within clinics for GPs to review results. Staff had a good knowledge of tasks within their role and systems were in place to escalate concerns such as safeguarding concerns and new cancer diagnoses. There were systems in place for summarising new patient records and a member of staff completed checks to ensure these had been appropriately recorded and patients’ needs such as allergies were flagged on the system.

We did not receive any specific comments from patients relating to this area.

Staff confirmed they had received training relevant to their role and understood how to escalate concerns. An online system was used for safeguarding training and clinicians had completed level 3 safeguarding training. Safeguarding concerns were escalated to the safeguarding leads, and further action was taken where required. There were separate safeguarding leads for adults and children. Concerns were shared at weekly and monthly meetings. Where there were safeguarding concerns relevant patient records were now linked. The practice had good support from the local authority.

Information on improvement actions taken to safeguard patients had been shared with the Integrated Care Board (ICB).

There were improved systems for staff training and monitoring patients on safeguarding registers. An online system was used to provide staff with safeguarding training and clinicians attended an annual face-to-face level 3 training session. The records, used to monitor training completion, showed 82% of staff had completed level 2 safeguarding adults and children, however, the training matrix records did not show the level 3 training completed for clinicians. A list of clinicians who had attended the June 2024 level 3 training was provided and clinical staff we spoke with confirmed they had attended this training. The practice completed quarterly audits of children with safeguarding concerns. This audit reviewed patients who had safeguarding information documented on their record but were not yet on the safeguarding register. The outcome determined whether the patients needed to be added to the safeguarding register. The checks included risk factors, such as high attendance at A&E, high non-attendance rates and attendance at out-of-hours services on a regular basis. Business minutes showed safeguarding was a standing agenda item and cases were discussed in meetings.

We did not receive any specific comments relating to this area.

The practice had access to a social prescriber employed by Citizens Advice, the practice used an online referral system to refer patients to the service, and the social prescriber occasionally came into the practice.

The practice used an online referral system to refer to a social prescriber, and the social prescriber occasionally came into the practice. The training matrix showed training had been provided for staff in learning disability and autism in general practice. Training was also provided for staff in disability awareness, chaperoning and managing violence and aggression. 76% of staff had received training in basic life support for children, 71% in infant life support and 85% had adult basic life support training. Improvements had been made in provision of emergency equipment and each site now had its own defibrillator and new emergency drug trolleys.

Some staff told us they would like to see better maintenance of the building at Crowle and others raised concerns about access to car parks and unevenness of paths. However, others said there had been improvements made to the building including decoration, new automatic double doors at the entrance and a new staff room. Maintenance staff told us they felt supported. Detailed improvement action plans were provided.

We saw all sites were clean and tidy and health and safety checks had been maintained. We observed improvements had continued to be made to each of the three sites. For example, at the Keadby site we observed a new fire door had been fitted upstairs and patient records were now secure, new vaccine fridges had been purchased and there was evidence of up-to-date portable appliance testing. At the Crowle site the building had been decorated, new automatic double doors had been fitted at the entrance and a new staff room had been provided. Fire records showed fire drills had been undertaken and regular weekly and monthly testing of the fire systems was completed. However, the fire records at Keadby showed internal fire doors required repair as they were not closing tight to. The fire risk assessment completed in October 2023 identified the issues with the fire doors. Evidence was provided to show work to address the issues was in progress and further work was due 30 August 2024. Only a fixed position couch was available in the GP clinic room at Keadby and the clinician told us they would use another room with an adjustable couch where necessary for less mobile patients.

The provider had improved systems to manage the environment at each site. They had developed a detailed action plan for improvement in response to our last inspection in May 2023 and had completed much of the work required. We found improvements in the maintenance of the buildings and, although some work was still ongoing, evidence was provided that this was scheduled for completion. Work at the Keadby site included full refurbishment with new flooring throughout the building, new fridges, furniture, and lockable cabinets for the safe storage of medication and prescriptions. New flooring had been provided at Skippingdale site toilet areas and some decorating and maintenance work to grounds had been completed. Cloud based telephony system had been installed across the organisation. Portable appliance testing and calibration of equipment had been completed at each site. Fire risk assessments had been completed for each site and actions had been taken to address identified risks or work was scheduled. Electrical work had been undertaken, adding additional plugs and removing extension leads. Legionella checks had been maintained and monitored. The provider had a facilities manager whose role included ensuring regular monitoring checks such as fire and legionella checks were being completed and staff training was up to date. The training matrix showed 84% of staff had completed fire safety training. A detailed business continuity plan for all sites had been developed and included significant incident procedures.

We received mixed comments from patients. Some patients told us they found staff to be helpful and they said they had received good clinical care, but other patients felt some staff were rude and didn't listen to them. One patient told us they had noticed a high turnover of staff.

A GP partner was the clinical lead. They told us they completed clinical supervision every month with the clinical team, and this included discussion about complex patients but stated they didn’t keep records of this support but would in future. Staff confirmed they had received clinical supervision and had regular meetings. Weekly clinical meetings were also held and records showed discussions about complex cases and learning was shared. Staff told us they were satisfied with training and support and there was support for further development. Some staff told us they did not feel there were always enough staff for example, clinical staff were not always available to work at each site every day as there was not always enough cover for sickness and holidays and rotas had to be cancelled at times. They told us they needed more general practice/treatment room nurses or nurse associates. Leaders told us there had been significant staff turnover, but the practice had also increased the number of care navigators and administration staff and had employed additional practice nurses and GPs. Some staff had very positive comments about working at the practice and thought they worked well as a team and were supportive to each other. They also told us the clinicians were very committed and cared for the patients and often go above and beyond. Staff told us they had had an appraisal or a meeting if still within their probationary period. The management team told us about their role in appraisals and monitoring of training. They were knowledgeable about the process and told us they were up to date with this work. They told us role specific training was also provided, and staff were reminded to complete training. Most staff said they felt supported by their managers, but some said the managers mainly worked from the provider main site, based in Brigg, and not often at Trent View sites and they felt this was impacting on communication.

There were improvements in processes to manage staff and training provision. There were systems in place for staff appraisal and clinical supervision. Online and face to face training was provided. Staff were able to access training specific to their role and to further develop. Systems had been developed to enable the provider to monitor staff training completion. An overview of training had been maintained showing the percentage of staff who had completed the training. An annual training plan had been developed but we noted the training plan didn’t always match the training completion monitoring record. For example, level 3 safeguarding was on the plan but not on the monitoring records although other evidence of completion was available. We reviewed 3 personnel files and found appropriate checks had taken place including disclosure and barring (DBS) checks. Induction records were completed, and staff had shadowing and competency checks recorded on file. New staff had a probationary period and team leaders met with staff during this time. Induction was provided and induction records were maintained. Weekly clinical meetings were held and records showed discussions about complex cases and learning was shared. Records showed all staff had received an annual appraisal or had a date scheduled.

We did not receive any specific comments relating to this area.

Staff told us they had received infection prevention and control (IPC) training. The nurse lead told us they had acted on findings from the IPC audits and had updated the policy and procedures. They told us they had also made improvements in the building and ensured staff were trained.

All sites were clean, tidy and well organised. A sample of single use equipment was checked at each site and was within the expiry date. Systems for the safe disposal of sharps and clinical waste were in place. Hand washing facilities and hand wash instruction posters were displayed.

Training in infection prevention and control (IPC) was provided. The training matrix showed most staff had had IPC training. Audits had been completed for all 3 sites and had identified some areas for improvement such as flooring. An action plan had been developed to address the findings, and some new flooring had already been fitted. Where the audits identified a staff training issue relating to stock control evidence was provided to show how this had been addressed and processes improved. Legionella checks had been maintained and monitored.

Staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely. One patient told us there had been a lack of communication before sending out messages about changes to their medicines which had caused them concern. Another person told us there had been some errors on their prescription for repeat medicines and they had not received all the medicines they had ordered.

Staff received regular training on medicines management, and felt confident managing the storage, administration and recording of medicines. Staff managed medicines-related stationery appropriately and securely. Staff followed protocols to ensure they prescribed medicines safely, and ensured people received all recommended medicines reviews and monitoring. One member of staff felt there were some delays from internal and external services in sending communications about changes to medicines to them which caused delays in updating patient records.

We saw improved processes in provision of systems to store medicines. Dispensed medicines in the dispensary at Keadby were now stored in locked cabinets, new vaccine fridges had been provided and emergency medicines at all sites were stored securely in new trolleys. Staff managed medicines safely and regularly checked the stock levels and expiry dates for all medicines, including emergency medicines, vaccines, and controlled drugs. However, there was a limited system for stock check of medicines in the dispensary. A new monitoring system by an external pharmacy company was to commence in October 2024. Staff stored medical gases, such as oxygen, safely.

The provider had developed and improved systems to manage medicines. The provider had systems in place to respond to safety alerts, medicine recalls and high-risk drug monitoring requirements. However, some staff had not always followed established processes to ensure people prescribed medicines with specific risks had received recommended monitoring and advice prior to approving repeat prescriptions. For example, two patients prescribed an immunosuppressant medicine had continued to be prescribed their medicine without the required monitoring having been completed. Patients prescribed an anticoagulant medicine had had the required tests to check their kidney function completed previously but had not had this repeated in the last 12 months. Five patients prescribed a combination of medicines which was the subject of a safety alert had not had the required blood tests to check their kidney function in the last 6 months. A medicine for pain which was also the subject of a safety alert was prescribed to a patient of child bearing age but there was no evidence in the patient record that the risks had been discussed with the patient.

Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. Prescribing data reviewed as part of our assessment confirmed this. For example, the number of antimicrobials issued by the provider was lower than local and national averages. There was some evidence of clinical auditing of prescribing that focused on improving care and treatment. These were single cycle audits and follow ups had not been completed at the time of the assessment to show if any improvements had been made.