Whittington Moor Surgery

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

There was a proactive and positive culture of safety based on openness and honesty, in which concerns about safety were listened to, safety events were investigated and reported thoroughly in most cases, and lessons were learnt to identify and embed good practices. Medicines and treatments mostly met people’s needs, capacities and preferences by enabling them to be involved in planning, including when changes happen. However, we found systems were not fully effective to mitigate risks in the absence of recommended emergency medicines, tracking of prescription stationery throughout the practice, ensuring staff had the appropriate authorisations to administer medicines and the supervision and audit of non-medical prescribers. This was a breach of regulations and the provider is subject to an action plan to remedy the breach. We also found that not all clinical staff were aware of where some of the emergency equipment was kept and there was a risk of electrocution due to unsafe usage of an examination lamp.

This service scored 87 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

As part of the announced inspection at Whittington Moor Surgery in February 2024, the views of the practice team were sought as part of the evidence category of staff feedback. A questionnaire was sent to the practice manager to circulate to all team members who were asked to return their questionnaires to the CQC assessor by 16 February 2024. All eleven responses were treated confidentially. The feedback was mostly positive. Staff were able to report that they were aware of the incident reporting process and knew how to report concerns. Responses indicated that learning was shared from events to improve services. Staff attended meetings regularly, and discussed relevant issues, and information was also shared electronically via notifications on the practice IT systems. Almost all responses highlighted that the practice was very focussed upon patient care and providing the best service to meet their needs. Some non-clinical staff expressed some dissatisfaction with managers, saying they did not always feel supported, and that staff welfare required greater focus. However, other non-clinical staff and clinicians spoke positively about an inclusive and supportive leadership with a clear vision for the future.

We found that complaints were fully investigated, and learning was applied as appropriate. Patients received a full response to their complaint however, from the two complaints we reviewed, we found that patients were not made aware of the right to go to the PHSO if they were unhappy with the outcome of the investigation into their complaint. The practice had received 18 complaints in the last year. We did not receive any feedback from patients via Give Feedback on Care forms as part of the assessment.

We found that the practice monitored and reviewed safety using information from a variety of sources including significant events and complaints. Staff told us they knew how to identify and report concerns, safety incidents and near misses. Learning from significant events and complaints was shared with staff and systems to identify trends in significant events and complaints were in place. Where changes had been implemented in response to learning, the effectiveness of the changes made were reviewed. Patients were supported to give feedback through complaints and compliments. We found that complaints were reviewed on a 6-monthly basis to identify trends and that when it was appropriate to do so, learning was shared with staff. There was a system in place for staff to raise significant events that had occurred within the practice. Significant events were investigated, learning from them was shared with staff and systems to identify trends in significant event were in place. The practice was proactive in raising significant events and 38 significant events had been raised and investigated in the last 12 months. We reviewed two of them and found that a thorough investigation had been completed and when changes had been implemented to avoid issues occurring again that the effectiveness of the changes made was reviewed.

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.

Feedback received from the Integrated Care Board (ICB) as part of the assessment showed the practice engaged in medicines management and optimisation programmes. During our onsite inspection we found that there were no medicines kept in the practice to treat hypoglycaemia or any reference to these medicines on the practice’s emergency medicines list. A risk assessment had not been completed to demonstrate how they would mitigate potential risks. The provider informed us they would give jelly babies however, these were not available with the emergency medicines. Following our inspection, they sent evidence that they had chocolates that they would give to diabetic patients that experienced low blood sugar. A risk assessment to mitigate risks of allergic reactions such as nut or gluten allergy, choking in potentially unresponsive or semi-conscious patients, the inability to monitor the amount of glucose provided and the inability to monitor the expiry date of the chocolates had not been completed.

There was emergency equipment and some emergency medicines to keep people safe and processes for checking these on a monthly basis were in place. However, we found that medicines used in the treatment of low blood sugar, seizures, nausea and vomiting and severe pain were not available within the practice and risk assessments to mitigate potential risks had not been recorded. Not all clinical members of staff were aware of where all of the emergency equipment was kept. Following our inspection the provider sent evidence that they were addressing these concerns. At our onsite inspection we found there was no record of the prescription pads stored in the practice to enable tracking of prescription stationery throughout the practice. Following our inspection the provider informed us that the prescription pads had been destroyed in line with national guidance.

There was a process in place for receiving and acting on medicines alerts, including those received from MHRA, with follow up audits conducted to ensure patients were reviewed in line with the alerts. Our remote clinical searches found overall systems in place were effective with medication reviews undertaken. Further evidence provided by the practice following discussion on the outcomes of our clinical searches provided assurances on the efficacy of medicines management and oversight. Processes in place to assess and manage medicines held on site were not fully effective. During our onsite inspection we found that up to date appropriate authorisations to administer medicines were not in place when HCAs administered vitamin B 12 vaccines. We found that the authorisation for the administration of a vitamin B 12 injection provided to a patient on the day of our inspection had not been updated or reviewed since 8 December 2020. Following our site visit on 19 February, the practice provided us with updated protocols regarding B12 management. Two Patient Group Directions (PGDs) had not been signed by a practice nurse. This was remedied soon after the inspection. Systems for tracking prescription stationery throughout the practice were ineffective. Following our inspection the provider informed us they would not record the sequencing of the numbers to support the tracking of prescription. They were unaware of the national sequencing of prescription stationery identification numbers. Systems were not in place for providing clinical supervision for non-medical prescribers. A policy was developed following our inspection to support the implementation of audit and clinical supervision for non-medical prescribers. Following the site visit, the provider had undertaken a prescribing audit of the nurse prescriber in February 2024, reviewing 10 consultations from January 2024. This was comprehensive and highlighted good practice and areas for potential improvement.

The practice worked with patients to discuss their prescribed medications and when appropriate look at alternative medicines due to risk or potential addition concerns. The most recent GPPS results indicated that patients feel involved in decisions about their care, this will involve discussions relating to prescribing 93% were involved as much as they wanted to be in decisions about their care and treatment during their last general practice appointment; compared to local average of 91% and national average of 90%.

The practice had a clinical audit programme to support positive outcomes for patients. For example, the practice had undertaken an audit to review percentage of 'c' drugs prescribed within total antibiotic prescribing. This demonstrated that overall compliance was good, although registrars/locums needed support and advice to ensure their compliance was improved. Data on antibiotics prescribing for the treatment of uncomplicated urinary tract infections showed the practice performance was positively below national averages. Trends over time show this has been consistent since 2020. Prescribing of pregabalin or gabapentin was above national averages. This has been consistent over time. Prescribing of psychotropics was above national averages.