Cookham Medical Centre

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 assessed 2 quality statements in the safe key question and found areas of concern. The scores for these areas have been combined with scores based on the rating from the last inspection, which was good. Though the assessment of these areas indicated areas of concern since the last inspection, our rating for the key question remains good. We found 1 breach of legal regulations related to good governance and we have asked the provider for an action plan in response to the findings at this assessment which were: Staff were confident in the Duty of Candour process. Staff were confident about how they could raise a concern in the practice and that the practice would respond. Systems and processes to identify, record, review, and learn from significant events existed. However, learning was not shared promptly throughout the practice. Monitoring of patients prescribing did not always follow guidance and monitoring was not always checked before prescriptions were issued. Patients’ records did not always contain complete and accurate information about their diagnosis. A new system to manage medicines safety alerts from the Medicines Healthcare products Regulatory Agency (MHRA) had been introduced but was not effective. Systems to monitor the stock level and expiry dates of emergency medicines existed but decisions to not stock medicines had not been risk assessed. The system to manage prescription stationary was not effective. Not all staff were qualified to prescribe medicines and where staff operated under Patient Specific Directions (PSDs) the system to authorise them had not followed guidance.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We asked the provider to share details of our Give Feedback on Care process with patients. We received 3 pieces of feedback during the assessment and reviewed submissions dating back to June 2023 which included 12 further pieces of feedback. We also reviewed the results of the GP Patient survey and reviews on the NHS website. None of the feedback reviewed related to this quality statement.

We spoke with 8 members of staff during the assessment and found all were either able to explain the process of how they would report significant event activity (SEA) or who they would seek guidance from to do so. We also found many staff could share examples of SEAs where learning had resulted. Although staff were able to share examples of SEA’s where learning had resulted, not all staff were clear about how they would find out about the learning. For example, we had mixed findings about whether SEA’s were discussed routinely at practice meetings. This finding supported a concern from our evidence review that learning may not be shared promptly enough after a significant event occurred because the SEA policy stated theme and trend reviews would occur approximately bi-annually. We spoke with the leadership about this, and they provided verbal assurance that learning would never wait until this meeting because it would be shared immediately to ensure changes and improvements were made. We found staff were confident to raise an incident and that the culture was to learn and not blame. Discussions with staff about the whistleblowing procedure found a similar ethos existed regarding staffs’ attitude towards raising a concern. Staff we spoke with stated they would have no concerns about admitting a mistake, offering an apology, and being involved in a complaint or significant event investigation. In summary, our discussions found safety was a priority for staff and the practice and, there was a culture of reviewing incidents which led to learning. This was enabled by an open, transparent, and supportive approach to the management of incidents.

Our review of evidence and processes that operated within the practice found: There was a significant event activity (SEA) policy which detailed the practices’ definition of a SEA and what staff should do to report a SEA. The policy stated all SEA’s would be reviewed approximately 6 monthly at a meeting and we reviewed the minutes of this meeting which showed this had happened. The practice recorded SEA’s on a log which detailed the immediate action taken and the type of event, which supported the practice to identify themes. However, our review of the policy and conversations with some staff raised concerns that SEA’s were not discussed routinely outside of the bi-annual review meeting. We reviewed minutes of clinical and non-clinical meetings within the practice, which supported the concern because it was not clear that SEA’s had been discussed in those meetings. We reviewed the practice’s duty of candour policy which clearly recorded the practice sought an ethos to not fear raising a concern because it documented that any genuinely made mistake would not be held against a member of staff. The policy also showed the practice wanted service users and visitors to the practice to be assured that any incident would be thoroughly investigated and reported upon. The policy also stated the practice wanted a culture of learning to support improvement in safety and the quality of health care. Overall we were assured that the practice had a culture that encouraged incidents to be raised, learning to be identified, and which ensured risks were not ignored or overlooked and improvements were made. Most systems and processes supported this ethos; however, improvement was needed to ensure meeting minutes clearly documented SEA’s had been discussed.

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.

We asked the provider to share details of our Give Feedback on Care process with patients. We received 3 pieces of feedback during the assessment and reviewed submissions dating back to June 2023 which included 12 further pieces of feedback. Almost all the patient feedback was positive but did not relate directly to this quality statement. However, there was 1 piece of feedback which reported it had taken a long time for the practice to prescribe a medicine. The patient also stated they had not had a review of their medicines and the practice did not provide blood tests. We also reviewed the results of the GP Patient survey and found all results were above the national average, including, the indicator related to people’s overall experience of the practice which was relevant to the provision of safe care and treatment.

Our observations, reviews of processes, documents and outcomes found that patients care and treatment did not always reflect current and relevant best practice and professional guidance and that people were not always appropriately involved in decisions about their medicines. We discussed the findings with the practice to understand whether systems and processes had not operated as the practice expected or whether there was additional information required to understand the findings. Regarding our findings that 4 medicines safety alerts from the Medicines Healthcare products Regulatory Agency (MHRA) had not been followed. It was accepted that by the practice that their new system needed to become embedded, and it was confirmed that the system searched for patients affected by alerts on a repeated basis. After the searches, the practice provided outcomes of their reviews of the patients affected by these findings which gave some mitigation for the risk. Regarding our remote clinical searches indicating monitoring was not always confirmed to be up to date before prescriptions were issued. The practice confirmed the clinical system alerted clinicians when patients were overdue monitoring. There was also a dedicated member of staff responsible for recalling patients and the system to identify and recall patients was explained. Having identified the system to manage blank prescription stationery was not effective the practice updated us during the assessment they were immediately improving the system by changing the default printer to a single printer in a secure area. This removed the need to issue stock to staff. They would also destroy any stock that could not be accounted and had followed national guidance when doing this. Overall we found the practice was responsive to feedback and acted when issues were identified, however, these explanations did not alter the fact that improvements were required to ensure medicines were managed safely.

Our observations found the process to manage the cold chain within the practice had operated effectively which ensured medicines requiring refrigeration were managed safely. Systems and processes to monitor the stock levels and expiration dates of emergency medicines existed and our observations found these had operated effectively, however, the practice the practice did not stock all recommended emergency medicines. These included a medicine to treat seizures and a medicine to treat pain. The other medicine was to treat symptoms of slow heart rate and national guidance recommended this should be stocked when fitting contraceptive coils. After identifying this to the practice, they immediately ordered the medicine and postponed any future coil fitting appointments until it was stocked. For the other 2 medicines we were shown minutes from a meeting in 2017 where the decision was made not to stock the medicine, but the minutes did not confirm the guidance referred to. We found the practice did not have an effective system to manage blank prescription stationery. Upon identifying this to the practice they immediately acted to improve the system. While on site we sampled 6 Patient Group Directions (PGDs) and via our remote interviews we sampled 2 Patient Specific Directions (PSDs). These are instructions that allow some healthcare professionals to supply and administer specific medicines to specific groups of patients, without them needing to see a prescriber. Our observations found the PGD system operated correctly but the PSD system did not because the authorising prescriber had not completed the form and strength of the medicine on the form before the medicine was administered. This had been added to the patients’ clinical record afterwards and not by the prescriber. Overall our observations found patients’ medicines were not always prescribed or administered in line with relevant guidance and, not all systems, processes and governance was effective.

Our GP specialist advisor (SpA) completed remote clinical searches on the practice’s clinical system. These identified 16 patients prescribed gabapentinoids which are medicines used to treat neuropathic pain and occasionally epilepsy. They are Schedule 3 Controlled Drugs and can be liable to abuse and misuse. The GP SpA reviewed a sample of 5 patients' records and found no concerns. Our GP SpA sampled 5 medication reviews and found 4 contained appropriate detail, however, 1 lacked information about what had been reviewed. However, we found a new system to manage medicines safety alerts issued by the Medicines Healthcare products Regulatory Agency (MHRA) had been introduced to improve the process because the old system did not record the action taken in response to an alert. Our remote clinical searches identified 4 alerts where the practice either had either not acted or it was not clear from the patients record what action had been taken. The system had been introduced just before the assessment and our findings indicated it was not completely effective or embedded yet. Our GP SpA found no evidence that the prescriber had checked monitoring was up to date before issuing the last prescription for 3 groups of patients. Without the necessary monitoring there was a risk that it was not safe to continue prescribing these medicines because dose adjustments could be required, and the patient could also be at risk of side effects. The remote clinical searches found the monitoring of 2 patients prescribed lithium had not included a check of their calcium level. The remote clinical searches identified 6 patients with a potential missed diagnosis of diabetes. Our GP SpA reviewed 5 patients. Their findings were that 3 patients were diabetic, but the diagnosis was not coded in their record. The practice reviewed all 3 patients and agreed 2 patients were diabetic but provided further information to explain why the other patient was not diabetic.

Performance data from external data sources showed the practice had positive performance for 2 indicators related to prescribing. This indicated that the practice was aware of current guidance for these medicines. We also saw evidence that the practice audited prescribing to ensure targets and guidance were followed and that where outliers were identified, the practice acted to improve performance. For example, an audit of prescribing of an antibiotic medicine showed there were examples where current guidance had not been followed. The practice reviewed the patients and found the prescribing had been initiated by another service but shared the learning. Feedback was provided by the practice to the Integrated Care Board (ICB) to explain the findings.