Friarsgate 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 and inspected against two quality statements, Learning culture and Medicines optimisation. During our assessment of this key question, we found people did not always receive care and treatment in line with national guidelines. People with long-term health conditions and those prescribed high-risk medicines were not always monitored to ensure their health did not deteriorate. When medicine reviews did take place, records were not always sufficiently comprehensive to demonstrate it was safe to continue prescribing. This was a breach of regulation 12 safe care and treatment, of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. During our assessment of this key question, we found clinical staff did not have the support of a formalised system for clinical supervision. Staff did report that they had support from other colleagues and leaders. The practice investigated and responded to complaints and significant events appropriately, they could demonstrate that learning was reviewed and disseminated to the staff team.

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 3 'Give feedback on care' submissions as part of this assessment. People told us that they had opportunities to provide feedback and they knew how to make a complaint. People told us they had enough time during their consultation, and they felt involved in decisions about their care and treatment.

Leaders told us that safety incidents were investigated and recorded on a significant events log. Staff and leaders understood their duty to raise concerns and report safety incidents and near misses. GP partners together with the business manager told us they were responsible for investigating incidents which required clinical review. Staff were aware what learning had taken place following the review of safety incidents to know what changes were needed to improve care for people.

Records of complaints and significant events set out what lessons had been learned from all safety incidents or complaints and what changes had been made to improve care for other people. Minutes from practice management meetings showed significant events were discussed. We saw an example of actions taken as a result of a significant event where action was taken to review the process for receipt, handing and dealing with urine samples. A new protocol was introduced, staff training, and support provided, and the process underwent evaluation and improvement. There was evidence of sharing this information and the learning outcomes with all staff. The practice had a complaints policy in place which included a complaints response timeframe of 3 days for initial response and 21 working days for investigation. Further acknowledgement communication was sent to people that exceeded this timeframe. We identified that the practice had recorded 6 complaints and 30 concerns in the last 12 months. Learning outcomes had been shared with staff and teams. From the sample of complaint records we reviewed; we found the practice responded to people’s complaints in a timely manner. The practice incident reporting system complied with the requirements of the duty of candour.

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.

People’s feedback in relation to the safe management of their medicines was limited. However, people told us they had a good response when making repeat prescription requests. The practice vaccine programme was well coordinated. Further feedback confirmed that acute prescriptions were arranged promptly following consultations.

As part of our assessment, we discussed with the medicine lead the outcomes of our review of the practice records. We discussed the lack of information in medicine reviews. For example, patient records were coded as reviewed with no evidence of review for 3 patients we looked at. The medicines lead was not aware of these concerns, or the other areas of concern including the lack of appropriate healthcare checks and prescribing found during our searches. Following our review of clinical searches, the registered manager took immediate action in relation to concerns raised by our assessment team. Leaders told us that emergency medicines were checked regularly, and systems were in place to monitor and respond to patient healthcare needs. Staff told us they received appropriate training and guidance in relation to medicines administered through Patient Group Directions or Patient Specific Directions. We were told by staff that they had access to safety and medicines alerts. We were given examples of actions taken. Staff told us they had not received formal supervision. Staff told us they felt supported in their roles otherwise and had access to colleagues and leaders. We noted from the practice risk assessment Annual Medication reviews that moved to Primary Care Network (PCN) pharmacists were moved back to GP responsibility in Summer 2023 following an audit.

During our on-site visit, we observed that the practice had medicines stored for emergencies. These were kept up to date and monitored. The practice had not risk assessed whether they had stored a specific emergency medicine and did not have a protocol in place for all expected emergencies. Appropriate facilities were available for the storage of medicines and regular audit took place on stocks, and particularly the medicines fridges. We identified an issue relating to the appropriate storage of medicines, including vaccines which required refrigeration. We observed that not all fridges at the practice’s branch had been appropriately locked to ensure access was restricted from members of the public and other organisations using the same premises.

There was a lack of a fully embedded process for monitoring peoples’ health in relation to the prescribing of high-risk medicines, with blood monitoring requirements in accordance with national guidelines and effective medication reviews. There was evidence that the process for managing safety alerts was in place. We were told by staff that they had access to safety and medicines alerts. We were given examples of actions taken. However, we did not see a system for tracking all alerts and the actions taken, nor was there a system for recording responses to these alerts. We observed that Patient Group Directives (PGDs) were not always authorised by a manager for new staff when they had signed an existing document. We noted that newly issued PGDs were appropriately signed and authorised. There was a lack of audit to ensure this remained compliant. Whilst we saw a policy on appraisal and supervision with accompanying recording formats, there was no evidence of clinical supervision. The practice had taken steps to ensure appropriate antimicrobial use to optimise patient outcomes and reduce the risk of adverse events and antimicrobial resistance. The most recent data seen by the assessment team confirmed this and that the practice was in-line with local and national averages.

During our remote clinical searches, we found that patients who were prescribed high-risk medicines were not always monitored appropriately to ensure safe care and treatment was provided. People’s records were coded as having a medicine review with no detail of this review. Not all patients had the required healthcare monitoring. For example, we saw a patient had been prescribed an anti-inflammatory medicine and antiplatelet medicine with no protection against the risk of bleeding. Another patient had been prescribed a medicine used for the treatment of gastroesophageal reflux disease or peptic ulcer disease and a medicine used to reduce the risk of heart disease and stroke. This combination was advised against by Medicines and Healthcare Products Regulatory Agency (MHRA) alert and there was no evidence that the risk had been considered. Another record showed that a patient was overdue a medicine’s review. When we looked at the patient’s record, we saw a review code added with no evidence of review. It had not been identified that the patient had an anti-inflammatory medicine on repeat prescription and no medicine prescribed alongside to reduce the risk of bleeding. Another patient noted on record as anaemic had their last haemoglobin test in June 2022 and there was no repeat of this test since. We saw that this patient was not taking a medicine for gastroprotection despite taking another medicine that increase the risk of bleeding. Therefore, there was the potential for increasing risk of worsening anaemia. We brought this to the attention of clinical staff who took action to follow up on this patient as a priority.