Abbamoor Surgery

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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 reviewed 8 quality statement in the Safe key question – Learning culture, Safe systems pathways and transitions, Safeguarding, Involving people to manage risks, Safe environments, Safe and effective staffing, Infection prevention and control and Medicines optimisation. There was a culture of safety and learning. Staff we spoke with told us they were encouraged to raise concerns and felt supported in doing so. Incidents and complaints were appropriately investigated. There was an effective system for reporting, recording, and learning from significant events. Learning from complaints was routinely shared with staff. Risks were actively managed and viewed as an opportunity to learn and improve. Our review of the remote searches of patient records showed that patients were being effectively and safely managed. There was a process for the management of medicines, including high risk medicines, with appropriate monitoring and clinical review prior to prescribing. Patients were involved in regular reviews of their medicines. Medicine management was effective. Expiry dates of medicines were monitored, recorded and all in date. Fridge temperatures were recorded daily, and no temperatures had gone out of range. Medicines were stored correctly either in locked cabinets or locked fridges. Prescription stationary was kept securely, and their use monitored in line with national guidance. Staff had the appropriate authorisations to administer medicines (including Patient Group Directions or Patient Specific Directions).

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People told us they had enough time during their consultation to ask questions and feel involved in decisions about their care. They told us they felt safe receiving their care at the practice and that it was always clean and tidy. There was access for people to a friends and family form in the practice and on the practice website to understand patient experiences. We noted the practice had received 4 complaints in the last year. We saw evidence they had all been investigated and people were informed of outcomes. In the reception area we saw information for patients about the complaint's procedure was visible.

Staff we spoke with told us they were able to raise concerns and, report when things went wrong. We reviewed minutes from meetings, which evidenced that clinical issues were regularly discussed between members of the team at the practice, and within the wider Primary Care Network, where applicable. Staff we spoke with told us incidents were discussed in team meetings to understand the actions and the learning. Staff we spoke with told us there was an open culture and they felt able and encouraged to raise concerns.

The practice policies and processes were accessible to all staff to support their work. Risk management processes at the practice enabled the identification, recording, monitoring and review to prevent, mitigate and manage risks/incidents. Leaders described a system for recording and acting on patient safety alerts. There had been 1 significant event in the last 12 months, and we saw incidents were fully investigated. There was evidence that changes had been made as a result of identified learning. We found incidents and complaints were appropriately investigated and managed. Meeting minutes demonstrated staff were updated regularly about actions taken by the practice to improve, and any learning to be adopted from incidents/events. When things went wrong, staff apologised and gave patients honest information and support. The practice had a complaints policy in place which outlined the complaints process. This was accessible to patients on the practice website and a complaints leaflet was available. The practice had a duty of candour policy in place which was last reviewed in February 2024, and we saw that it was considered as part of the complaints and significant events.

The national GP patient survey carried out from January to April 2023 showed that 96.3% of patients said last time they had a general practice appointment; the healthcare professional was good or very good at treating them with care and concern. The national average was 84%. Results showed that 99% of patients stated they were involved as much as they wanted to be in decisions about their care and treatment. When asked about accessing the practice, 79% stated the experience of making an appointment was very or fairly good, which was above national average. CQC have received 1 complaint in the last 12 months. CQC did not speak to patients on the day of the on-site inspection.

The leaders and staff told us there was a system to ensure referrals to specialist services were documented, contained the required information and there was a system to monitor urgent referrals and any delays, which was the responsibility of a designated partner. The process followed the patient through their entire hospital pathway until either diagnosis or discharge so that no diagnosis was missed. Staff told us there was a documented approach to the management of test results and these were reviewed in a timely manner and there was appropriate clinical oversight of the results, including when reviewed by non-clinical staff.

The leaders submitted copies of Integrated care meetings for March 2024, these demonstrated working within a multidisciplinary team to discuss and improve outcomes for people with complex needs. We had no feedback from any external partners.

There was a system to ensure referrals to specialist services were documented, contained the required information and there was a system to monitor urgent referrals and any delays. The practice had a system to monitor the uptake of referrals. There was a documented approach to the management of test results, and this was managed in a timely manner. A review of the pathology results and workflow tasks demonstrated they were dealt with promptly.

The practice had a safeguarding GP lead who was allocated time to review patients where there were safeguarding concerns. The safeguarding lead met monthly with the health visiting team. The practice also monitored children who were not brought to appointments. Non-clinical staff were aware of who to report any safeguarding concerns to. Staff we spoke with were aware of female genital mutilation (FGM).

We had no feedback from any external partners.

The practice had systems, practices, and processes to keep, people safe and safeguarded from abuse. A review of patient records found the practice had a system to highlight vulnerable adults and children to staff. The practice had safeguarding children’s and vulnerable adult’s policies which provided information for staff to follow to enable the safe response to a safeguarding concern. We saw safeguarding training records that showed most staff were trained to appropriate levels for their role. However, two staff whose files we reviewed had not completed essential adult safeguarding training. Immediately following our inspection, the provider sent us evidence of completed adult safeguarding training for the staff we identified.

The national GP patient survey carried out from January to April 2023 found 99% of patients had confidence and trust in the health care professional they saw or spoke to. And 88% patients responded positively to how easy it was to get through to someone at their GP practice on the phone. CQC have received 1 complaint in the last 12 months. CQC did not speak to patients on the day of the on-site inspection.

Leaders told us there was an effective approach to managing staff absences and busy periods. However, some staff told us there were not enough reception staff to meet patient demands. Receptionists told us the actions they would take if they encountered a deteriorating or acutely unwell patient and described how they would allocate patients to the different clinicians.

The practice was equipped to respond to medical emergencies (including suspected sepsis) and staff were suitably trained in emergency procedures. Staff had completed the appropriate training for anaphylaxis and basic life support training. The practice had a locum induction pack for agency staff to follow.

The provider told us that facilities and equipment were safe, and that equipment was maintained according to manufacturers’ instructions. There were systems for safely managing healthcare waste. Staff explained any maintenance concerns were promptly responded to by the leaders.

The practice maintained good standards of cleanliness and hygiene. There were reliable systems in place to prevent and protect people from a healthcare associated infection. Arrangements were in place to managing waste and clinical specimens. The practice was equipped to respond to medical emergencies and staff were suitably trained in emergency procedures.

Health and safety risk assessments had been carried out and appropriate actions taken. The practice had completed fire risk assessments, fire drills and emergency lighting checks. The practice provided evidence of annual portable appliance testing, and calibration of equipment. Infection prevention and control audits were carried out. We checked 5 staff files and found 1 member of staff had not completed their fire safety training. Staff had completed fire warden training.

The national GP patient survey carried out from January to April 2023 found 99% of patients had confidence and trust in the health care professional they saw or spoke and 96% stated the health care professional was good at treating the patient with care and concern. CQC have received 1 complaint from during the last 12 months. CQC did not speak to patients on the day of the on-site visit.

At the time of the assessment, a new practice nurse had recently started working at the practice. There was one clinical pharmacist, employed by the PCN, who completed medicines reviews. The leaders told us they had a system in place to review the consultations and ensure the competency of allied and clinical staff. The leaders explained staff had completed annual appraisals.

The practice had a recruitment policy. However, current recruitment and new starter checks needed strengthening, including oversight of required references and risk assessment in the absence of references. We found some gaps in staff recruitment records. We saw that all staff whose files we checked had a DBS check completed. Following our inspection, managers took prompt action to review the gaps in recruitment records. The leaders submitted a staff training matrix; however, we found not all practice staff had undertaken essential training at a level appropriate for their role. We found gaps in mandatory training for four members of staff which included infection control training, fire safety, adult safeguarding, equality and diversity, Mental Capacity Act training. Staff told us they were given protected time to undertake essential training. Staff vaccination: The practice had a staff immunisation policy, but it had not always been followed. The policy included reference to vaccination/immunity to Hepatitis B for all staff who might come into contact with body fluids, clinical waste and sharps in the course of their duties. There was no record for 4 members of staff that they had been screened and completed a Hepatitis B immunisation course. At the time of our assessment, there was no risk assessment available to mitigate any risk for those staff members whose files we checked. This was not in line with the practice policy or Green Book recommendations. We saw new staff received an induction. There were regular review meetings for new staff and all staff had an annual appraisal. The practice employed several staff in advanced clinical roles. There was a structured system for clinical supervision which included regular protected time for supervision meetings, daily debrief sessions and audits of non-medical prescribing.

During this assessment we only received feedback from 1 patient, they had no concerns regarding the infection control of the practice, and fed back that the practice was always very clean.

The leaders explained that the practice nurse was the lead for infection prevention and control, and they carried out regular checks of all the premises. Staff and leaders told us they had systems and processes in place to monitor and manage infection control.

We visited the practice site and found appropriate standards of cleanliness and hygiene were being met.

Staff had completed an infection prevention and control audit in January 2024 and had a system in place to ensure that the rooms were checked daily. The practice had completed a legionella risk assessment.

We did not receive a lot of patient feedback. We asked the practice to share details of CQC Give Feedback on Care process on the practice website, however at the time of the assessment we did not receive GFC feedback from the practice’s website.

Clinical staff were able to tell us about how they monitored patients’ health in relation to the use of medicines including high risk medicines. Staff informed us of the process to ensure appropriate clinical oversight of test results. Staff we spoke with were knowledgeable about systems and processes within the practice that enabled positive patient care. We saw the practice had undertaken a range of audits to develop and improve the quality and care given to patients.

During our on-site checks we found all medicines were stored securely. Prescription paper was stored securely, and the practice maintained a record of prescription paper serial numbers. Emergency equipment and medicines were checked on a regular basis. Vaccines were ordered and stored in accordance with national guidelines and the practice has systems in place to monitor the temperature of vaccine fridges.

The provider had processes in place to manage and respond to national patient medicine and safety alerts. Leaders explained how this worked to assure patient care and treatment safety. Nominated staff members managed the process to determine which alerts required urgent action and treatment or medicine changes. Our clinical searches identified 42 patients taking SGLT-2 inhibitor. These are medicines used to treat type 2 diabetes. An SGLT-2 inhibitor alert was issued by Medicines and Healthcare products Regulatory Agency (MHRA) in February 2019. We looked at a sample of five patient records. Three out of the five patients had not been informed about the side-effects of their medication. The provider sent us their written response following our assessment confirming that they contacted these patients and provided them all with information about the risks of taking SGLT-2 Inhibitor medicines. Patient group directives (written instructions to help with the supply or administration of medicines) were in place and had been signed by staff and the authorising lead in line with national guidance. Prescriptions were stored securely, and a record of serial numbers was maintained. Cold chain and medicines storage policies were in place. Vaccines were ordered and stored in accordance with national guidelines and the practice had a process to monitor the temperature of medicine fridges. The practice held appropriate emergency equipment and emergency medicines and risk assessments were in place to determine the range of medicines held, and a system was in place to monitor stock levels and expiry dates. At the time of our on-site inspection, two emergency medicines were not available, and the practice sent us their risk assessment and emergency drugs rationale for not having these emergency medicines. Following our inspection the practice obtained prednisolone medicines to treat croup in children.

The practice completed annual health reviews for patients with long-term health conditions and those on registers such as learning disability, palliative care and safeguarding. These registers were reviewed regularly, and reports run to identify any on-going monitoring needs for patients. During the searches undertaken as part of the remote assessment we found effective structured medicine reviews were carried out. There was evidence of effective medicines reviews for patients on repeat medicines and we found the number of medication reviews completed in last 3 months was 186. We reviewed a sample of 5 of these patients and found no concerns. During the remote interview with the GP, they explained the regular reporting undertaken monthly to monitor the treatment and medicine reviews of patients. The practice had systems and oversight in place to monitor the appropriateness of non-medical prescribers and clinical supervision was documented. The provider had created a cloud based automated call and recall system to improve management of patients with chronic diseases - hypertension, diabetes and atrial fibrillation. The system was successfully piloted with partners in the Havering North PCN between October 2022 and September 2023 and outcomes showed a significant improvement in chronic disease management and improved health outcomes for patients. Leaders told us the system had won awards for health innovation. The practice had effective systems in place for the safe management of their clinical correspondence workflow. Accurate and up-to-date information about people’s medicines was available, when they moved between health and care settings. The practice had systems and processes in place to effectively monitor and manage patients’ high-risk medicines. Antibacterial prescribing was in line with national averages for prescribing.