The Limes 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

At the last inspection, we found that there was a lack of oversight for safeguarding processes, there were gaps in staff recruitment, and training, learning and improvement needed strengthening. At this assessment we identified concerns in the management of patient safety. This included health and safety, fire safety and the security and premises. We found the practice did not have effective systems and procedures to keep patients safe. Patients’ needs were not always assessed, and care and treatment were not always delivered in line with current legislation, standards and evidence-based guidance supported by clear pathways. There was limited oversight, induction and supervision for staff and learning from incidents and significant events had not been embedded to ensure people’s safety was integral to the care and treatment they received.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Information reviewed demonstrated that people had opportunities to provide feedback, however we were not assured that the practice were actively reviewing and following this up consistently. Feedback and information were available in the practice and on their website. People told us they had enough time during their consultation, they felt involved in decisions about their care and treatment and had confidence and trust in the healthcare professional they saw or spoke to.

Staff and leaders told us of the systems in place to investigate concerns and share learning, however we found that this was not consistently followed. For example, we found that staff were able to raise concerns, however they lacked the confidence that their concerns would be investigated and managed appropriately. We found that not all staff were involved in investigating significant events and complaints and identifying learning. We found practice meetings were not consistently held so any actions or lessons learned was not routinely shared. Staff gave examples of clinical incidents that had been raised with leaders but had not been investigated. Feedback from staff demonstrated that the practice had a poor culture of identifying all incidents and complaints and sharing learning to embed good practices. Some staff told us that their high workload meant that training and learning was not prioritised and at times completed outside of their working hours.

We found that the practice had systems and processes in place to investigate and report incidents, however these were not routinely followed or actioned. For example, we found evidence of a poor learning culture and missed opportunities to raise significant events or incidents during our assessment. We found meetings were not held with staff to consistently share learning and found some examples of significant events which evidenced a poor blame culture. At the time of our assessment, the practice was migrating to a new learning system for online training. Records we viewed demonstrated significant gaps in staff mandatory training. For example, safeguarding, chaperoning, equality and diversity and infection control was out of date for clinical and non-clinical staff.

Information we reviewed during our assessment demonstrated that there was a backlog in reviewing and monitoring patients in a timely way. However, we saw evidence of feedback from patients during our assessment which showed some areas of satisfaction. For example, 86% of patients stated that the last time they had a general practice appointment, the healthcare professional was good or very good at listening to them. The local average was 83% and the national average was 87%.

Leaders told us that clinicians made appropriate and timely referrals in line with protocols and up to date evidence-based guidance, however we were unable to gain assurances that there was an effective system in place to ensure all patient information which included documents, laboratory test results and referrals were reviewed and actioned in a timely manner. During our assessment it was unclear who had the responsibility for overseeing the process of tasks and referrals being actioned as clinicians managed their own patients lists. We were told that there were limited buddy arrangements in place for clinicians in their absence and we found a lack of clarity or consistency to provide cover arrangements leading to backlogs in patient care.

The provider told us that there were processes in place to keep people safe. Although we found some evidence to demonstrate that meetings were held where patients were reviewed, this did not demonstrate that there was a consistent approach amongst all clinicians to ensure that people were managed safely and appropriately to maximise high quality care.

We were not assured that the practice had processes in place that were robust or effective to keep patients safe and managed in a timely way. For example, results from blood tests were allocated to the GP who requested them, but in their absence, we were not assured that cover arrangements were managed safely. For example, some clinicians refused to sign prescriptions in other GPs absence. We found clinicians were working independently rather than collectively and the lack of cohesion meant that patients did not receive the appropriate care and treatment in a timely way. We found that the system for processing information relating to new patients including the summarising of new patient notes was not managed safely or effectively in line with general data protection requirements (GDPR). We were not assured that the process for two week wait referrals was robust. For example, referrals were made in a timely way, however there was a lack of process in place to proactively follow these up and monitor them appropriately.

Results from the national patient survey demonstrated that 85% say the healthcare professional they saw or spoke to was good at treating them with care and concern during their last general practice appointment and 70% say the healthcare professional they saw or spoke to was good at considering their mental wellbeing during their last general practice appointment.

The practice had a safeguarding lead for adults and children and policies in place to support staff in the event of a safeguarding concern. Staff we spoke to were not able to share specific examples where safeguarding had been discussed but told us they would report any safeguarding concerns to the safeguarding lead. We were told that the safeguarding lead held meetings with other agencies to review any safeguarding concerns and were supported by a non-clinical staff member who was tasked in updating safeguarding registers. The practice held a safeguarding register, and clinical system alerts were used to identify patients who were at risk of harm or abuse, however we found these were not routinely monitored and there were gaps in safeguarding registers that required strengthening.

We spoke with the safeguarding lead who told us they routinely met with safeguarding teams such as the health visitor and midwife to review safeguarding and we saw evidence of meeting minutes in place.

There were policies and processes in place to support safeguarding, however these needed strengthening. For example, safeguarding registers were not always accurately coded where safeguarding concerns had been identified. Clinical system alerts were used to identify patients who were at risk of harm or abuse, however the system in place was not managed effectively and this had been identified during our last inspection in April 2022. We were told there were processes in place to follow up children and young people who were not brought to their appointments both at the practice and for secondary care appointments, however we were not assured of this process during our assessment. We found that all staff, with the exception of 1 clinical and 1 non clinical’s safeguarding training was out of date. At the time of our assessment, we found there was no overall leadership to manage essential training.

Results from the national GP survey results demonstrated that 93% of patients had confidence and trust in the healthcare professional they saw or spoke to during their last general practice appointment which was above local and national averages.

We found some evidence that leaders worked with other agencies to understand and manage risk, but this was not always consistent. The practice had registers in place to support those patients who were vulnerable or who had mobility or communication needs, however we found a lack of processes and oversight in ensuring these were routinely monitored. We found gaps in staff training and some staff had not completed sepsis awareness training, however staff were aware of actions to take if they encountered a deteriorating or acutely unwell patients.

We found that processes required strengthening to ensure risks were managed appropriately. For example: we found clinical risks in relation to patients prescribed high risk medicines, those that had long term conditions and those with a potential misdiagnosis. We found concerns during our assessment that some patients had not been monitored appropriately or followed up to ensure they were receiving the care and treatment. There were some processes in place to ensure the practice prioritised care for their most clinically vulnerable patients, however we were not assured that patients were told when they needed to seek further help and what to do if their condition deteriorated. For example, our clinical searches found there was 24 patients with a potential misdiagnosis of diabetes. We sampled 5 of these patients and found the practice was not following best practice guidance and following these up appropriately. There were some systems in place to support patients who face communication barriers to access treatment (including those who might be digitally excluded), however we found there was no hearing loop available at reception.

Staff told us that that health and safety, security and maintenance of the building was not regularly reviewed to ensure this was to a safe standard. During our site visit, we were told that the lights in the reception areas and patient toilet had been broken and had been replaced the day before the assessment visit. In addition, we were told that there had been no hot running water for several months. Overall, we found that areas within health and safety were reactive, rather than proactive. We found staff had not completed training in health and safety, and infection prevention and control. There was no evidence that a recent fire drill had been carried out and the building was being regularly maintained. In addition, staff told us that workplace assessments had not been carried out for staff in line with health and safety executive (HSE) legislation. Although leaders could provide evidence that a boiler service, fire safety checks and portable appliance testing had been booked in after our site visit, there was a lack of overall leadership to ensure this was safely maintained in a timely way to ensure risks were acted on and were being safely maintained. We found some staff were out of date with training updates, which included fire safety training.

During our site visit we found that the premises were not well maintained and found concerns that areas within health and safety and fire safety had lapsed and had not been appropriately actioned. We checked the running water and found that this was not to the required temperature, nor was the provider aware of the length of time this had been an issue. Portable appliance testing (PAT) and fire extinguishers had not been maintained and there was a lack of processes and concerns around the security of the building. We found a lack of overall leadership in place to manage this safely and asked the provider to take immediate action.

We found concerns in the lack of processes in place to manage the safe environment of the practice. There were policies and procedures in place for the management of health and safety, however some areas had not been maintained and immediate action was required to address the shortfalls.

The results from the national patient survey demonstrated that 75% find the reception and administrative team at this GP practice helpful, 45% usually get to see or speak to their preferred healthcare professional when they would like to and 61% say they have had enough support from local services or organisations in the last 12 months to help manage their long-term conditions or illnesses

There were policies and procedures in place for the safe recruitment of staff. We saw evidence that disclosure and barring checks for all staff working in the practice had been undertaken. We did not find that there were clearly defined lead roles to support staff in carrying out their roles effectively. For example, we found that the practice was without a full-time practice manager and staff told us that they managed themselves and had not received effective leadership, support or supervision in some instances for over 18 months. Mandatory learning for staff was overdue and was not being appropriately monitored. We found that staff were not up to date with training requirements. There were staffing rotas, however this was not managed effectively. For example, staff told us that there were shortfalls to cover clinical and non-clinical activities due to some staff leaving and not being replaced. We were told that during annual leave, there was limited cover arrangements in place for specific roles and lone working arrangements had not been risk assessed. Due to the lack of communication amongst the workforce, staff at times had been unaware of who was working in the building

We did not gain assurances that the practice had clear processes in place to manage safe and effective staffing. We identified numerous staff had not updated their training and staff reported they were provided with no time to do this. There were processes in place for staff appraisals, but we found some staff were overdue and had not had one in over 12 months. There was a lack of oversight to manage staff induction and rotas to ensure there were adequate arrangements in place to meet the needs of the service. For example, we were told that the practice had closed the doors to patients on occasions due to being understaffed. The practice could not demonstrate how they assured the competence of staff employed in advanced clinical practice, for example, nurse practitioners, paramedics and pharmacists as there was a lack of oversight, audits and clinical supervision arrangements in place.

We did not gain feedback around infection prevention and control with patients during this assessment. However, the shortfalls we identified in relation to the premises and environment could impact people’s experience. You can find more details of our concerns in the evidence category findings.

The practice had an infection control lead in place who had undertaken an audit in May 2024. We were told that IPC was undertaken by the nursing team who reviewed IPC every 3 months. There were policies and procedures in place and staff were aware of who the IPC lead was in the practice. We were told that IPC was being reviewed, however there were areas within the building that were difficult to rectify due to the building.

We observed the general environment to be tidy, however we found one of the privacy screens was visibly dirty and some of the chairs had been ripped. Sharps bins were available in all clinical rooms which were signed, dated, safely sited and were not over-filled.

The practice had policies in place for infection, prevention and control. There, was an infection control lead in place and an infection control audit had been carried out in May 2024; the practice had achieved 92%. However, we found that IPC training was overdue for both clinical and non-clinical staff working in the practice

Results from the national patient survey demonstrated that 61% of patients told us they have had enough support from local services or organisations in the last 12 months to help manage their long-term conditions or illnesses which was below local and national averages. However, the shortfalls we identified in relation to medicines management were impacting on people’s care. You can find more details of our concerns in the evidence category findings

The practice told us they worked with the clinical pharmacists from the local Primary Care Network to identify prescribing and management of patients receiving high risk medicines and medicines which require monitoring; however, we were not assured that there was clear oversight. During the clinical review we found that not all medicine alerts had been acted on and high-risk medicine and long-term conditioning monitoring was overdue for patients.

We found that vaccines were appropriately stored, however we found on the day of the site visit that the data logger for the fridge had not been switched on. We found that not all recommended emergency medicines and equipment were available, and an effective risk assessment had not been completed. For example, dexamethasone (a medicine typically used to treat croup) and Midazolam (buccal) or Diazepam (rectal) a medicine typically used to treat seizures were not stocked and this had not been appropriately risk assessed. We found that patient group directions or PGDs (a written instruction for the administration of medicines to groups of patients not previously prescribed for) were in place but had only been signed by 1 of the 2 nurses working in the practice.

Clinicians did not always work with up-to-date evidence-based guidance, and we found that systems required strengthening to ensure processes such as patient information including documents, laboratory test results and cytology reports, patient monitoring and reviews were actioned in a timely manner. We found there was no collective approach to manage this effectively or consistently amongst clinicians. Our review of patient records in relation to the clinical searches identified that care records was not always managed in line with guidance and legislation. Clinical searches of patient records were carried out as part of our inspection. A medicine (methotrexate) to treat rheumatoid arthritis which requires regular blood monitoring due to the risk of side effects, was looked at. It was found that of 23 patients who were prescribed the medicine, 8 showed as overdue monitoring. We sampled 5 of these patients and found all were overdue blood tests and were not assured that blood results taken in secondary care were being reviewed before a prescription was issued as this was not documented within the patient records. Our searches identified 8 patients were prescribed an aldosterone antagonist without appropriate monitoring. We reviewed 5 patients for potassium sparing diuretics (a medicine used to treat heart failure, cirrhosis or hypertension) which showed the practice had significant problems in identifying the overdue status of these patients. Our searches found a patient was prescribed metformin with a very low renal function which has been present for at least 18 months with no follow up. A search on missed diagnoses of diabetes showed that 24 patients had been identified. We reviewed 5 patients and found the practice had not followed national institute of clinical excellence (NICE) guidance to confirm the diagnosis of diabetes and to implement appropriate referral and management.

During the inspection we identified concerns in the management of high-risk medicines, safety alerts and medicine reviews which meant that patients had not been identified or followed up in a timely way. We found that there was no robust system in place to ensure the practice had taken action to review safety alerts to ensure that these were being followed appropriately to ensure people were protected from harm. There was no clear process in place for recalling patients to ensure they had access to appropriate monitoring and information to manage their health needs. There was no clear process for acting on safety alerts. Records of actions taken against alerts were not evidenced. A search to look at an MHRA alert to monitor patients’ renal bloods on a combination of 2 medicines 6 monthly at least, showed 7 patients were overdue. Monitoring based on this MHRA alert was poor. We found that long term conditions clinical searches showed that patients were not always monitored or followed up within an appropriate timescale or reviews did not demonstrate best practice guidelines. For example: Our clinical searches found there was 17 patients who had been prescribed 2 or more courses of rescue steroids. We found that 13 patients required a steroid card and found that 2 patients were overdue a review. Overall, we found issues with some of the coding of these patients and a lack of safety netting in the patient records. We found there were 32 patients with hypothyroidism who had not had a thyroid function test in the last 18 months. We reviewed 2 of these patients and found these were overdue. Clinical care records showed a lack of oversight and structured medicines management review. Where a review had been carried out for patients, we found individual care records were poor and contained minimal or no commentary and were not adequately documented.