Lister 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 rated the practice Inadequate for providing safe services because there were inadequate systems, processes and practices to keep people safe. The practice did not always have systems for the appropriate and safe use of medicines, in relation to ensuring the security of blank FP10 prescription forms from theft and misuse. There was a risk that patients would not receive timely treatment in the event of an emergency, due to inadequate systems and processes in place for the management of emergency medicines. There were inadequate systems and processes to manage cold chain monitoring and to ensure vaccines were managed properly so that immunisations were carried out safely and efficiently. There were gaps in the learning culture of the practice in relation to the management and processing of significant events and complaints. There were gaps in staff training, infection prevention and control was not always managed safely.

This service scored 25 (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 in various different channels. As part of our inspection, we reviewed patient experience sent to CQC, online feedback, complaints and significant event records and feedback provided via the Patient Participation Group (PPG). The practice did not respond to all feedback and we saw evidence some patient complaints were never responded to and they were raised with CQC.

Staff told us they were aware of the incident reporting process, knew how to report concerns and some of them were invited to governance meetings where significant events were discussed; however, 2 staff members told us they were not invited to meetings and did not have incidents and learning discussed. There was a significant event policy and a system to record significant events. Although risk was identified, we were not assured they were adequately managed to prevent repeat occurrences. When we reviewed the significant events from 2022 to 2024, we found 19 out of 94 incidents had not been effectively reviewed. We saw recurring incidents documented on these logs, demonstrating a lack of learning from significant events to prevent recurrence. For example, a 5ft piece of metal window ledge fell from height with a risk of danger to life. Although we saw swift action taken to notify the relevant persons who came to check this and all seemed secure, there was no evidence provided to show what steps were taken to ensure this incident would not occur again. A patient was abusive towards staff and police were involved but there was no in depth root cause analysis and a statutory notification was not submitted to CQC as per regulatory requirements and this also included when a child's tooth was knocked out whilst running around in the waiting room. There were also no assurances on how the provider would reduce the risk of accidents relating to children playing in the waiting room. The practice ignored the identified risks around a significant amount of blank prescriptions we found in clinical rooms and all request for information on this data were not responded to. A completed significant event form around this finding was not provided. Staff attended meetings regularly and we saw evidence of learning in some areas; however, this was inadequate to ensure people were not placed at risk of harm due to inadequate safety culture. The provider took action post inspection.

We reviewed a wide range of patient feedback and this ranged from complaints sent to CQC, online feedback, complaints sent to the practice, as well as their significant events that showed people's experiences with regards to safe systems and pathways. When we reviewed complaints sent to CQC, we found patients raised significant concerns around their referrals to secondary care being unactioned by the practice. One patient told us their referrals had been delayed by a month, with inadequate responses from the practice. In the complaints we viewed, the practice had gone over the 3 day complaints acknowledgement period. We also reviewed a complaint sent to the integrated care board (ICB) regarding issues with two referrals. Other feedback included a patient being told a referral had been made for them to the local hospital but there were no details provided, such as the department and contact number and they tried to ring the practice to obtain this information but access was difficult and the patient had waited a month without any appointment for this referral. People also told us of their frustrations regarding the newly implemented total triage system, that hindered them from being able to access the service, which in turn had an impact on their care. Patients told us this system led to the provider being unable to provide the most basic care.

Administration staff responsible for sending referrals between services told us they used a traffic light approach which they worked through to distinguish the urgency of referrals. They also told us they monitored referrals and chased medication lists from the discharging hospitals. Leaders told us urgent referrals were actioned on the same day and all patient referrals and tasks were monitored weekly. Some staff told us the main challenges to delivering good quality care were secondary care referral delays; for example, 2-week wait referrals were seen but some patients were having to wait 52 weeks for a routine cardiologist referral. We saw staff feedback through significant events of the impact lack of staff had on the timely actioning of test results.

The provider worked with local care homes and we were told the provider usually sent the advanced care practitioners over a GP. Care home feedback was negative to this issue and although the practice was working for a solution, there was still progress to be made. The practice told us they would arrange an appointment with the care home, patient and family members and complete a thorough medicines review. The care home told us this did not happen face to face and review calls were multidisciplinary team virtual meetings. Care home staff wanted to see more GP presence in the home to avoid delays in care or treatment. We spoke to Healthwatch who told us that the feedback from the practice had been mixed, with access being a challenge due to the use of the new online triage system not being well received by patients. The provider told us they had taken this feedback on board and were in the process of looking at what changes could be made.

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. Information we reviewed during our inspection demonstrated that there was a backlog in referrals being actioned in a timely way. A significant event from February 2024 showed 111 accident and emergency reports had not been reviewed due to staffing issues. On the day of inspection we continued to find gaps in these processes in relation to abnormal test results as 108 outstanding results were waiting to be actioned, with the latest abnormal test dated 20 May 2024. The practice reported 5 referral related incidents since December 2023 which included 2-week wait referrals causing delays in patient care and one where a partner returning from leave had not been informed , suggesting a gap in processes. We saw evidence where the provider provided safe continuous care following patients discharge from hospital. The provider carried out a discharge summary audit in June 2024 for 14 patients aged 65 and over who had been discharged from hospital within the past 6 months, to determine whether their medicines reconciliation had taken place within 48-hours as per the practice recommendations and to assess the current condition of the patient. The audit found there was 100% compliance when it came to processing discharge summaries and documenting changes required within the recommended 48 hours.

Staff told us they had a good understanding of safeguarding, were able to raise safeguarding concerns and felt confident in doing so. Most of the staff were aware of the safeguarding lead, although one staff thought the safeguarding lead was the deputy lead. Staff we spoke to were able to tell us what constituted a safeguarding concern. Staff told us they collaborated with the MASH team and carried out quarterly reviews of patients on the safeguarding registers. They also told us regular audits of the safeguarding registers were taking place. Staff told us they were up to date with safeguarding training relevant to their roles; however, one clinician had not completed any child or adult safeguarding training as per training matrix records. The practice told us at risk patients had alerts placed on their records, including family members so they could be supported. All children who did not attend appointments were followed up with a telephone call and letter. If a child attended A&E or out of hours appointments, the practice would follow them up the following day.

There were gaps in some safeguarding processes where a child was registered without the other parent's knowledge and the provider had not carried out due diligence before registration, due to the nature of the case. There was a clinical and administrative safeguarding lead in the practice; however, according to the practice's safeguarding policy dated February 2024, a clinical deputy safeguarding lead for adults and children had not yet been confirmed. Practice policy stated all staff would receive annual refresher training; however, this was inconsistent with their training matrix of 3-yearly training. Their policy was to ensure staff placed the appropriate read codes on patient records; however, the safeguarding policy did not document what these read codes were, so they could not assure themselves patients were read coded accurately and in line with policy. Although the practice told us there was a process for the transitions of care, the information relating to when a patient transitioned from child to adult services was not documented in the combined adult and child safeguarding policy. The practice told us there were 200 children and 100 adults on the safeguarding register; however, our searches of their clinical system showed 48 children placed on the register on a protection plan and 334 children were at risk. Therefore, we were not assured all children at risk were being captured on the practice's at risk register. There was a DBS and chaperone policy in place, with evidence of chaperone notices displayed around the practice. Chaperone training for staff undertaking this role was up to date but there were gaps in safeguarding training for clinicians. For example, healthcare assistants were upskilled to annual reviews and wound care; however, we were not assured they've received the appropriate level of training for their roles. Overall, we were not assured of adequate systems and processes to safeguard people.

People told us the practice was unable to manage the clinical risks to patients and meet their care needs in a way that was safe and supportive. We received feedback from patients raising concerns that due to being unable to access the practice's online system and being told they could not make any appointments in person, they felt stranded. Over the past year, CQC received 54 patients experiences where patients reported not feeling safe and supported by the practice as risk to their health was not being managed in a timely way and exacerbated by the online booking system always being unavailable and long waits on phone lines, often abandoning the calls and leaving them at risk of further deterioration. Patient experience included an at risk cancer patient recovering from sepsis being unable to access the practice for regular blood test monitoring due to the online booking form being unavailable and with no risk assessment in place, they were at risk of further deterioration without the timely GP input. Some patients told us they experienced delay in medication changes when moving between services and some patients expressed their frustrations of being unable to book an appointment with the practice. One patient reported having to wait 3 months before their medicines were adjusted by the practice as instructed by secondary care, placing them at risk of deterioration and people told us of being dismissed by the practice when trying to access urgent care for children below 5 years of age and relevant risk assessments were not being made to ensure patient safety. Patients themes collected from online reviews, patient feedback to the practice and to the CQC, significant events and complaints showed patients could not get information and advice about their health, care and support.

Leaders told us this methodology of total triage had been implemented to reduce waits for people and they told us due to patient safety, they were only able to offer 2000 total triage appointments per day. Although the provider recognised this was a blend of administration and clinical appointments, patient safety had to be prioritised for clinicians to be able to safely review patients with appropriate appointment times. When managing patient risk in relation to reviewing and actioning abnormal results, the practice told us they expected abnormal test results to be actioned on the same day; however, they were not necessarily actioned on the same day but they were looked at. The provider had completed a staff survey in October 2022 which had shown staff did not always feel they were listened to by leadership about concerns raised to people's care and treatment assessments.

We were not assured the provider had reliable and consistent processes in place for working with patients, managing their risks and meeting their needs in a safe and supportive way. Whilst we saw examples of when clinical risk was managed when patients were able to access the service such as the monitoring and review of some patients with long-term conditions, the significant issues relating to the unavailable online form when the capacity of 2000 triage appointments per day, or less had been reached and the system that did not allow patients to book appointments in person, had a negative impact on the practice maximising their effectiveness of peoples care and treatment. This was consistent with patient feedback sent to CQC and on all online platforms that clinical risk was being missed. There were 22 patients who had a potential missed diagnosis of diabetes. The provider told us these patients were monitored, however our clinical searches found they were not following the national guidance in relation to abnormal average blood sugar levels. We saw an example of a patient who was still awaiting a follow up HbA1C blood test 13 months from the first and another patient was showing as possible diabetes but had received no follow up, or recalled for a diabetes review within 12 months of the blood test confirming diabetes, as per national guidelines. We also found gaps in how the practice managed risk in relation to acting on abnormal test results in a timely manner. On the day of inspection we saw 108 outstanding results were still waiting to be actioned, with the latest abnormal test dated 20 May 2024, nearly a month later and 14 other test results awaiting action dated between 5 and 10 June 2024. We saw significant events had been raised with regards to staff shortages leading to tasks unactioned; for example, in February 2024 a total of 2668 accident and emergency and NHS 111 reports had not been actioned and there was a risk of missed GP actions.

Staff we spoke to were aware of the fire safety procedures; however, some staff employed in the past year told us they were not aware of any fire drills having taken place and also not aware of the fire marshals in the practice. The provider told us there were 5 fire wardens in the practice. Fire drills were completed by the landlord; however, this was still awaited at the time of our inspection and the last one we saw completed was in 2023, consistent with new staff feedback. Staff told us they received fire safety training; however, 8 clinical and non-clinical staff had not received or were overdue the annual training. Staff told us they had completed DSE training on their website. We observed during our onsite visit that staff were quite isolated in the premises and there could be long delays of staff interaction. Staff told us there could be days where they did not see the practice leadership team. We were not assured the provider took sufficient action to ensure building security. For example, they recorded a significant event in February 2024 whereby they found keys left inside the lock of one of the rooms by the cleaners, which contained all master keys to the rooms in the building, leaving the building and its contents compromised and they noted that this was not the first time this had happened. The practice communicated with the relevant company who they noted did not appear concerned at this; however, the staff involved would be given a verbal warning. We found that although the practice had flagged their concerns with the relevant people, they had identified concerns with this company for months due to recurring incidents and they spoke of their intention to change them but there was no action taken to find other contractors due to the risk this current contractor was posing to the security of the premises.

There was medical oxygen on site with 2 full tanks. There was a record of portable appliance testing (PAT) and we observed random pieces of equipment such as weight scales and vaccines fridges to be in date. Fire extinguishers were checked and in date. The building landlords completed twice yearly fire drills although we noted a gap in 2023 when only 1 had been completed. The health and safety policy was vague and did not provide sufficient information to ensure health and safety at work was maintained and did not provide staff with any active links to referred documents such as the RIDDOR accident and injury reporting. The policy also stated to ensure that hazardous substances were assessed and any actions were implemented but did not specify what criteria had to be met for a substance to be considered hazardous, such as, toxic or irritants, or provide an outline of where the assessments were recorded, so staff could be aware. It was also not clear whether staff had been issued health and safety employee handbooks as identified by the risk assessment, as the action plan was not documented. There was no evidence provided to show that the related DSE risk assessments had been carried out for all individual staff to ensure that the hazards associated with display screen use were adequately controlled, as per the findings of this risk assessment. Therefore, we were not assured the provider was meeting all health and safety requirements. We observed there were secured blind loop cords around the practice. We saw 2 of the vaccines fridge temperatures were not checked consistently at the same time each day and some checks were carried out as late as 12.30pm.

The provider submitted two fire risk assessments dated February 2023 and due for review in February 2024 and a second fire risk assessment dated June 2023, due for review in June 2024. It was not clear why the provider carried out two separate risk assessments and they also told us the next fire risk assessment was scheduled for 11 June 2024. The fire risk assessment carried out in February 2023 assessed the premises as moderate risk of fire; for example, with regards to documentation where the fire safety records for each tenant of the premises was not available at the time of the fire risk assessment and there were no evacuation maps noted on each of the floors. We were not provided with any completed action plan for this risk assessment; therefore, could not be assured the required actions from this February 2023 assessment which had a specified 2-month time frame completion had been carried out. The fire risk assessment carried out in June 2024 also rated the premises at medium risk of fire; for example, the findings included fire doors being wedged open. There was evidence provided to show the practice had completed the action plan relating to this risk assessment such as where emails had been sent to staff regarding fire doors being wedged open, as well as other actions taken. We were also not assured that all appropriate risk assessments were in place; for example, a security risk assessment for the practice especially where it was laid over two floors and shared the building with other providers. We found the health and safety risk assessment carried out in June 2023 stated there was a legionella risk assessment in place; however, there was no evidence of an up to date risk assessment for 2024 at the time of our inspection. The practice only provided us with evidence of legionella water tests but there was no documented risk assessment or evidence provided of who the designated responsible officer was.

People told us that once they got past the obstacles of booking appointments, the staff they encountered were knowledgeable and provided good quality care. However, patient feedback highlighted significant concerns with staffing levels at the practice. People told us when they complained to the practice about poor access and lack of providing basic care, their complaints were not responded to in a timely manner due to the the practice management being extremely short staffed.

We completed staff interviews and obtained written staff feedback as part of our assessment. Staff told us they were DBS checked and underwent robust recruitment procedures. Although some staff felt staffing levels were sufficient, the majority of staff feedback raised issues around reduced staffing levels. Most staff raised concerns about the shortage of nurses at the practice due to long-term leave. Some staff told us there was enough capacity at the practice to deal with demand on most days; however, sickness and leave could affect this. Staff retention had also been an issue but staff told us the practice was actively recruiting and staff were offered overtime working hours. Some staff felt doctors were only working a few days a week so there were not enough appointments. Staff told us there were many staff across the practice that were multi-skilled and could cover sickness and leave most of the time. They told us processes were in place for when GPs were not working to ensure any administrative work was completed. Staff also told us examples of how they were supported to upskill themselves. For example, we saw staff who had began their career as a reception team member and were now in a clinical role. There was a dedicated GP assigned to oversee non medical prescribing staff. The provider was a training practice and supported GP registrar trainees in their development. Opportunities for upskilling staff was available and promoted by the provider. Leaders told us staff received supervision and appraisals annually. Staff told us they were mostly up to date with their mandatory training; however, we found gaps such as basic life support were due refresher training in the next month and some were overdue. New staff told us when they started working at the practice, they shadowed the different departments as part of their induction.

We were not assured there were enough qualified, skilled and experienced staff who received effective supervision due to the shortage of nursing staff who were qualified to undertake wound care. The practice told us the healthcare assistant (HCA) had been upskilled to undertake wound care in the past year; however, there was an incident whereby a patient attended with a painful abdominal wound which turned out to be an old wound packing left inside and had healed over, leaving the patient at risk of sepsis infection. There was no action taken to inform CQC under the duty of candour of this notifiable safety incident. We found gaps in sepsis training for staff where 9 clinical and 13 non-clinical staff had not received or were overdue sepsis training. We also found not all staff were aware of the sepsis red flags. Some staff had last received this training in 2019. The recruitment policy in place was due for review in May 2026 and although it mentioned temporary and locum staff, it did not provide sufficient information tailored specifically to the recruitment of such. The induction policy in place did not provide information tailored to locum staff such as GPs, or agency staff; therefore we could not be assured that all these temp staff were suitably experienced, competent and had the information they needed to work safely and effectively. This had an impact on patient care following a significant event in December 2023 where a locum GP provided a patient with an incorrect prescription, causing a data breach. We found gaps in their appraisal processes, in particular for 2023 where 9 staff appraisals were cancelled due to workload and staff sickness absence, with only 4 having been completed in 2024 at time of inspection. There was a staff training and development policy but gaps found in most of the mandatory training such as annual health and safety and data protection training.

There was an external cleaning company who cleaned for the practice; however, we were not assured of the quality of their service, nor of adequate oversight from the provider to ensure this company was meeting its contractual obligations. We observed cleanliness issues in the hallways, corridors and observed cleanliness and hygiene issues in toilet facilities. We discussed our observations with the provider who raised concerns about their cleaning contractor and showed evidence of communications with them as they were not cleaning the premises to an acceptable standard. The provider told us they were considering other cleaning contractor options; however, evidence provided shows the practice's dissatisfaction with the cleaning company had been subject to discussion as far back as October 2023, 8 months prior with no action taken to resolve this issue, or change to a different service. The delay in improving cleaning standards and ensuring the right cleaning contractors were working with the practice placed people using the service at risk of harm and this was consistent with the observations on the day of inspection and infection control incidents that took place in the practice. Although it was mandatory for staff to sign their daily cleaning schedules, we still saw incomplete daily cleaning schedules in 3 of the clinical rooms we viewed where none of the cleaning checklists had been completed fully. The training matrix provided showed there were gaps in mandatory 3-yearly waste management training for staff; for example, 10 clinical and non-clinical staff were overdue or not undertaken this training.

Whilst the practice put systems and processes in place to assess and manage the risk of infection, there was insufficient oversight to ensure infection control risk was being managed effectively as there were gaps in these processes. For example, the lead GP was the interim infection control lead at the time of our inspection and a healthcare assistant was being trained by the GP to take over as a lead but not all staff knew this. We found at least 3 staff were not aware of the lead GP as the interim lead. The last infection prevention and control policy was reviewed in October 2022 and the practice had undertaken various audits such as sharps and hand hygiene audits where actions were discussed and agreed. There were also procedures in place to deal with suspected notifiable disease cases. They provided a 2023-24 annual infection control statement which documented that in the past year there were no infection control incidents at the practice; however, this was inconsistent with their significant events records which showed during this period, there were 3 infection control related incidents; one which included clinical waste bags left out many times by the cleaners and containing sharps, posing a risk to staff and the public. There was an infection prevention action log based on the last audit that was still being completed; however, we were not shown a completed infection control audit for the practice. Their infection control policy stated that staff would receive annual refresher infection control training; whereas their training matrix stated 2-yearly training which was inconsistent. The training records showed training gaps where 9 clinical, including 2 nurses as well as 9 non-clinical staff had either not received the training, or hadn't completed it in the last year. Legionella checks were completed weekly and were up to date. Not all staff received immunisations and risk assessments were not always in place for those that did not have them.

We received 54 peoples experiences in the past year and there was mixed reviews given on medicines management. However, significant concerns were raised by patients regarding their medicines and delays in obtaining their prescriptions, whilst some found they were given their medicines on time. We received patient concerns that one diabetes patient diagnosed with Type 1 diabetes experienced consistent issues with obtaining their prescription from the practice, that they had to order their insulin days in advance so they would not run out. Other patients told us they could not get an appointment for their medicines reviews and some patients told us they were not provided with accurate and up to date information; for example, one patient told us their appointment was rushed so there was no effort from the clinician to explain the adverse reactions to their injected medicine. When the patient went to read on the side effects as they felt unwell afterwards, they found they had not been informed of the severity of the side effects and not given informed consent by the clinician. Some patients with multiple co-morbidities including mental health conditions told us they were desperate for their medicines reviews which included opiates but it was impossible to get appointments and the practice website always said the booking system was full, despite spending all day refreshing the system. When we looked at NHS verified feedback, we saw 33 mixed reviews received in the past 12 months, 19 of which were negative and consistent with the complaints shared with CQC mostly regarding access to care at the practice. Some patients reported that if they could not get through to the practice to book an appointment, the practice would stop their medication without any alternative, or phone call as to reasons why.

Staff told us pop up alerts were used to remind them of patients medicines reviews and ensure patients administered medicines were monitored appropriately. Prescribing staff told us they carried out medicines audits, such as antibiotic prescribing audits and had documented supervision. They told us of their responsibility to complete annual update training and implemented a process where there was a review of their prescribing competence every 1-2 months. Healthcare assistance undertaking vaccinations operated under a Patient Specific Direction (PSD). Clinical staff told us monthly patient safety alerts were discussed in their monthly governance meetings and they discussed an alert relating to pregablin (used to treat epilepsy and nerve pain) where alerts on patients prescribed this medicine were added. The provider told us that those people who had delayed medicines were because they were not compliant with medicine monitoring so their prescriptions were reduced until monitoring had been completed.

We observed emergency medicines were in a locked room with key coded entry. The provider told us this was appropriate and central to both floors. We requested the key code and we were given an incorrect code, which led us to find staff to gain access to the emergency medicines. The national resuscitation guidelines state emergency medicines should not be in locked rooms or cupboards. The emergency medicines were also placed inside a large trolley bag with no signage to indicate what they were. We observed the trolley bag was extremely heavy, difficult to open and wrapped with a type of bungee cord. Emergency medicines were not stored in individualised boxes, for example, vials of Chlorphenamine and Hydrocortisone mixed in one plastic vial sleeve and unboxed. There was no emergency medicines checklist or risk assessment for the emergency medicines as recommended by the national resuscitation guidelines. There was a risk of harm to patients if the emergency bag was inaccessible and mixed medicines meant they were at risk of being administered an incorrect medicine. We observed incomplete cold chain monitoring and the checks were completed by staff without the appropriate skills and competence to understand the significance. We requested to see the cold chain monitoring records and the practice could only provide May and June 2024 where we saw incomplete record keeping. We saw fridge temperatures were not checked at the same time each day as per national guidance; for example, on 7 May 2024, temperature was recorded at 12.30 pm whilst on 6 June 2024 the temperature was recorded at 10am and some entries were not initialled, including when the fridges were reset. We found inconsistencies in fridge stock, for example Pneumovax23 was recorded as 22 in stock on 14 June 2024 but we counted 10 in stock. There was no monitoring taking place of blank prescription forms and observed these prescription forms stored in unlocked clinical rooms.

We were not assured medicines management processes in the practice were always safe and met people's needs. There was a non-medical prescribing policy. The practice did not adhere to the policy relating to the safety of blank prescriptions. This policy stated it was the responsibility of each Non-medical Prescriber (NMP) to ensure the security of the prescription pads at all times; however, we found systems and processes were not established and did not operate effectively with regard to storing of blank FP10 prescriptions forms. These forms were not logged prior to being distributed in clinical rooms and there was no policy relating to their use with locum GPs, or when they were taken on home visits. There were inadequate processes in place to manage cold chain monitoring as the practice did not adhere to the policy. Fridge log sheets had missing information and temperature readings were not recorded on some days; for example Friday, 3 and 17 May for both fridges and there was no oversight to ensure these processes were being followed. There was a separate log of sheets for the previous 2 months that showed daily readings but the first day of the month always recorded a high temperature of 25 and 27 degrees Celsius, then reverted back to the recommended temperatures between 2 and 8 on the other days but it was not clear what this meant, or the significance of this document as the practice were not aware of this. Therefore, there was a risk that fridge contents were not stored correctly and unsafe to use. The repeat prescribing policy did not document that bar codes of stock received were checked against the delivery note or that prescription forms were not to be left in printers overnight. We did not see best practice guidance to retain these prescriptions forms for local auditing purposes for a short period prior to destruction as per national guidance The practice held prescribing and recalls meeting to discuss patient safety alert policies.

When we carried out the clinical records review, we found although systems were in place to review patients on high risk medicines, there were gaps in these systems that did not meet the national guidelines in relation to safe prescribing. For example, we saw there were 21 out of 47 people prescribed Methotrexate (used to treat inflammatory conditions) who had not received the appropriate monitoring. Of these 21, there were 2 people who had been reviewed at the hospital and had dose changes made. On the day of inspection, we found there were 3 out of 16 patients prescribed Lithium (mood stabiliser) who had not received the appropriate calcium blood test monitoring. The practice told us local guidance did not require this, however, this was inconsistent with national guidelines that set this as a requirement. For people prescribed Valproate used to treat epilepsy and bipolar, the provider had completed their part of an annual risk assessment, however, the local secondary care provider had not. The provider told us, despite chasing, that there was a lengthy delay from secondary care and it was a local-wide concern for all GP practices. The local integrated care board were aware of this and the practice told us they were supporting them to chase completion. There were 65 patients prescribed a teratogenic medicine. Of these, 1 patient had not received the correct contraception advice and the provider reviewed all of these patients and documented contraception advice by the time of our on site inspection. There were 2 out of 555 patients prescribed a thyroid medicine who were overdue a medicine review. The provider was aware of this and told us they had arranged an appointment prior to our assessment. The lack of emergency medicines risk assessment meant that there was a risk that not all recommended emergency medicines were available to ensure effective treatment to service users in an emergency.