Archived: Minehead Medical Centre Also known as Harley House

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 Inadequate for providing safe services because: The practice could not demonstrate that persons providing care and treatment to service users had the qualifications, competence, skills and experience to do so safely and that staff worked within their scope of competence. The practice was unable to give assurance that medicines were prescribed in line with practice policy and best practice guidance. There were not enough staff to provide necessary appointments to patients. There was no oversight of patients directed to use other services once appointment capacity had been reached. The practice was unable to demonstrate that acutely unwell patients would be identified and managed appropriately. The practice had a significant backlog of unfiled documents and there was no action plan in place to address this. The practice had a backlog of patient notes which required summarising. Oversight of this was not effective and there was no action plan to demonstrate how this would be managed. The significant event process was not fully embedded to ensure all incidents were identified and documented in a timely manner. The practice did not have effective systems to identify and action historic medicine alerts. The practice was unable to demonstrate that safeguarding alerts raised by external agencies were systematically reviewed by appropriate persons. Systems to monitor blank prescription stationary was not effective.

This service scored 6 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Practice systems to identify significant events were not embedded. We reviewed information shared with the practice by external agencies which identified patients who had been referred by practice staff to use other local services. This information demonstrated that these referrals were not always appropriate. While we saw the practice had conducted an initial review of this information, they had not raised any significant events for instances where there was risk of patient harm. For example, a patient with a suspected blocked shunt was referred by practice staff to attend the minor injuries unit rather than being directed to attend accident and emergency. (A blocked shunt can lead to a build-up of excess fluid in the brain, which can cause brain damage.) The practice had not raised this as a significant event and they were unable to demonstrate that practice staff involved were informed and that learning had been identified to try and prevent this from happening again.

Feedback from practice staff identified that significant events were not always reported in line with practice policy and that at the time of inspection, not all significant events had been documented. Staff told us that they had identified significant events but had not yet reported them in line with practice policy. At the time of inspection, they told us that this was a piece of work they knew they had yet to complete. Practice leaders told us that one member of staff was responsible for reporting all significant events, however this was not in line with practice policy.

The practice could not evidence that significant events were managed in line with policy. At the time of inspection, the practice manager told us that there were 4 significant events that had not been formally reported and therefore were pending investigation. Through discussions with practice staff, we also identified additional significant events which had not been formally reported. We raised this with the practice leaders who told us that one member of staff was responsible for formally documenting significant events, however they had been off work. This process was not in line with practice policy. The practice was unable to evidence that processes were embedded to identify and investigate significant events using information from a variety of sources. For example, when information demonstrating potential patient harm was raised with the practice through external stakeholders.

Feedback from patients included that there was a lack of continuity of care. Patients told us that they struggled to get appointments at the practice and were advised to seek medical assistance from NHS 111 and MIU. However, when they attempted to access these services, they were directed back to their GP practice which meant there was a delay in accessing medical care and treatment. During inspection we observed that clinicians did not always work collaboratively with other healthcare professionals who were involved in the care and treatment of registered patients.

The practice had not monitored access to ensure that patients were referred to use other services appropriately. The practice did not have a system for processing information relating to new patients. We identified 12 boxes of patient notes which required summarising. The practice was unable to advise when the backlog dated from as this had not been documented and an action plan had not been identified to clear the backlog. Practice leaders were unable to demonstrate an understanding of what was required to bring patient records up to date. They told us that all records had been RAG rated and that red and amber records had been summarised. On 28 December 2023 the practice sent us their monitoring spreadsheet which identified 17 ‘amber’ records had been summarised. However, there was no information to demonstrate what action had been taken for the remaining 55 ‘red’ records and 204 ‘amber’ records. The practice had told us that all patient records identified as ‘green’ had been received GP2GP and were automatically summarised (GP2GP is a system which allows the transfer of patients’ electronic health records). However, patient records received through this system still require review from practices to ensure necessary information is highlighted appropriately.

The practice had introduced a protocol for managing external healthcare professionals who contact the practice requesting to speak to a clinician. We reviewed the protocol and identified that it did not encourage collaborative working. For example, it encouraged reception staff to direct healthcare professionals to speak to their clinical supervisors within their own organisations. We observed this protocol in practice when a healthcare professional contacted the practice trying to prevent an unnecessary hospital admission for a registered patient. We saw that reception staff initially informed the healthcare professional to contact their clinical supervisors. On the persistence of the healthcare professional to speak with a practice clinician, there was a resistance from the relevant clinician to speak with them directly. Individual care records did not always contain necessary information. For example, medicines prescribed without a clear rationale. We identified medicine reviews which had been coded but no additional information provided such as what was included in the review and if medicines remained appropriate. At the time of inspection, the practice did not have a protocol for the use of econsult to ensure patients using this system were managed consistently and safely. (Econsult was an online consultation management system.) The practice had not monitored the use of this system to ensure patients were responded to in a timely way and that outcomes were appropriate. The practice did not have effective systems to ensure two-week-wait referrals were raised and managed appropriately. Our review of patient records identified: A 2WW was raised however the patient had not been informed of the referral. Two patients where care and treatment had not been managed and escalated appropriately. This had led to delays in cancer diagnosis.

Practice leaders were unable to provide evidence that safeguarding alerts raised by other health professionals were routinely reviewed. They told us that they did not have the capacity to review all alerts raised with them.

The practice had received support from local commissioners to improve safeguarding processes following our previous inspection. However, our inspection in December 2023 identified continued shortfalls in their processes.

At our inspection in November 2022, the practice was unable to evidence that all staff had received safeguarding training appropriate to their role. At this inspection, the practice was unable to evidence that staff were up to date with necessary safeguarding training. Following inspection, we requested this evidence to be sent to us, however this was not done. The practice did not have a process to systematically review safeguarding alerts raised by other health professionals. We identified one patient where a safeguarding alert had been raised by the ambulance service, however there was no evidence in their record demonstrating that this had been reviewed by the practice to determine if action was required.

At our inspection in November 2022, we found systems to ensure safety alerts were actioned appropriately were not embedded. At this inspection we found that necessary improvements had not been made to ensure appropriate actions were taken for all patients affected by medicines alerts. For example, we identified 6 out of 6 patients prescribed a medicine used for the management of epilepsy and anxiety who were of childbearing age, had not been advised of the risks associated with this medicine and pregnancy. Risk assessments conducted for emergency medicines held by the practice were not always valid or contained necessary information. For example, the practice had decided to stock intravenous paracetamol instead of morphine. The risk assessment had not identified if necessary staff had received appropriate training on how this should be administered. One risk assessment identified that the practice was not required to hold the medicine as the pharmacy next door would have access. However, at the time of inspection, there was no agreement with the pharmacy allowing the practice access to necessary medicines in an emergency. The risk assessment had also not identified what actions should be taken if the medicine was required outside of the pharmacy's opening times. The practice did not have effective systems to identify acutely unwell patients. Reception staff told us that they used their judgement to determine if a patient required an emergency appointment and that if they were unsure, they would speak to a clinician. They told us that when appointment capacity had been reached, they did not always get clinical oversight when they directed patients to use NHS 111 or the minor injuries unit.

Following our inspection in November 2022, the practice told us they trained additional staff to conduct fire alarm and legionella testing to ensure there was cover for annual leave and sickness.

At our inspection in November 2022, we found: Not all items identified on the practices fire risk assessment had been completed. A fire drill had not been completed in the last 6 months in line with their fire risk assessment and fire alarm testing was not done consistently. The practice’s health and safety risk assessment had not identified all areas of risk. For example, it had not identified that legionella testing had not been conducted consistently. At this inspection we found: Items identified on the practice’s fire risk assessment had still not been completed. The practice told us that they were halfway through replacing the consulting room doors in line with the risk assessment recommendations. They had not risk assessed the impact of this. Fire alarm checks and Legionella testing were conducted consistently. The practice had conducted a fire drill in the last 6 months in line with their fire risk assessment.

The practice did not have enough staff to provide appointments and prevent staff from working excessive hours. At the time of inspection, nurse clinics were fully booked until the middle of January 2024. Staff told us that patients requiring ongoing care would have planned appointments scheduled. However, there was no plan for patients requiring care for a new condition such as wound care following a surgical procedure. Staff told us they would squeeze patients onto the end of clinics where possible. No analysis had been conducted to identify the number of clinicians required and a minimum number of appointments to meet the needs of the patient population. Appointment availability was variable and patients were routinely directed to other local services when appointment capacity had been reached. The practice had not ensured they had enough qualified staff to address the document backlog. We were told the team responsible for working through the backlog consisted of 3 members of staff. However, staff were often required to assist in other departments such as the reception desk, due to staffing shortages. The practice told us an external company was due to assist in January and February to help reduce the backlog. However no action plan had been identified to demonstrate when the backlog would be cleared and what was required to prevent this from happening again.

At our inspection in November 2022, we found: Patient group directions (PGDs) were not always signed and authorised in line with guidance. The practice had not monitored the competencies of non-medical prescribers. There wasn’t enough staff to provide appointments and prevent staff from working excessive house. The practice had not monitored the coding or workflow team to ensure appropriate codes were applied, or that information received from third parties were reviewed as necessary. Not all mandatory training was up to date. At this inspection, we found: Patient group directions were signed and authorised in line with guidance. The practice had not monitored the competencies and prescribing practices of non-medical prescribers. We saw that a protocol had been drafted however, this had not been implemented at the time of inspection. Our review of patient records identified that not all decisions made by non-medical prescribers had been appropriate or in line with current guidance. The practice employed a clinician who was seconded from secondary care under Covid legislation. However, the practice was unable to provide assurance that duties they performed were limited to those set out in their contract. Our review of clinical records and discussions with staff identified they had provided care outside of their agreed competencies. The practice had not monitored the duties they performed and could not provide evidence that they received structured clinical supervision. No quality assurance processes had been introduced for the workflow and coding teams. The practice did not have structured training available for new staff joining the teams and there was no protocol to give ongoing guidance to staff to ensure documents were reviewed and actioned appropriately. The practice could not evidence that mandatory training was up to date. We requested that training records to be sent to us following inspection however, this was not done.

We discussed infection prevent and control with the practice lead and identified they held relevant training and an understanding of their role.

We found the practice had appropriate systems in place for managing infection prevention and control. However, cleaning equipment was not always appropriately secured from patient access or appropriately labelled. We found the key to the cleaning cupboard was accessible to patients and cleaning equipment was not labelled to identify areas of use which could lead to cross contamination. We saw vaccine fridge temperatures were checked twice daily. However, if the temperatures went out of range, additional information was not always recorded to demonstrate a cause and any action taken.

Practice staff could not provide assurance that there was an effective system to identify patients who had not received necessary monitoring for prescribed medicines. Practice leaders told us that monthly searches were conducted to identify patients who were overdue monitoring and that there was an escalation process should patients not engage. However, we identified that these processes were not embedded. We found medicines were issued to patients where required monitoring had not been conducted and the escalation process described by practice leaders, had not been followed.

At our last inspection, we found: Blank prescriptions were not monitored effectively. Medicine reviews did not always contain necessary information. At this inspection, we found: Systems introduced to monitor blank prescriptions were not embedded and did not ensure prescription stationary was monitored effectively. Improvements had not been made to ensure medicine reviews contained necessary information and patients received required monitoring. For example, we identified patients prescribed high risk medicines who had not received all required blood tests as part of their medicine review. We also identified a medicine review had been coded on a patient record in March 2023 with no additional information to demonstrate rationale for continued prescribing. Processes to proactively recall patients for a review of their care and treatment were not embedded. For example: We reviewed records of 4 patients diagnosed with hypothyroidism. We found all 4 patients were overdue required monitoring and not all patients had been recalled for a review. The practice told us that they had a system to identify patients with this condition who were overdue monitoring, however they were unable to demonstrate that these were conducted routinely and that patients were recalled as required. We also identified one patient diagnosed with Hypothyroidism where they had declined all monitoring. This code was applied by admin staff and there was no documented discussion with a GP demonstrating a clinical review and oversight of this action being taken. Patients diagnosed with asthma who were prescribed rescue steroids for acute exacerbations of their condition, were not always followed up as required. The practice was unable to demonstrate that they had a system to proactively identify these patients.

Our review of patient records identified that clinicians did not always follow best practice guidance. For example, we found: A non-medical prescriber had prescribed a non-NICE recommended treatment for restless leg syndrome. There was no documented rationale for this decision. A patient contacted the practice with symptoms indicating fluid on the brain. Reception staff spoke with a non-medical prescriber who directed the patient to attend the minor-injuries unit rather than attending A&E. (Fluid on the brain can be fatal if left untreated.) Our review of patient records identified a clinician seconded to the practice from secondary care prescribed medicines for conditions outside of their contracted scope of practice and demonstrated inappropriate record keeping supporting clinical decisions. For example: There were no clinical details, including clinical observations, to support the prescribing of antibiotics for a respiratory tract infection. Two patients were prescribed antibiotics for urinary tract infections. For one patient there was no record of clinical assessment to demonstrate they ruled out additional concerns such as sepsis. For the second patient, there were no notes on the patient record to support the clinical decision.