Larksfield Surgery Medical Partnership

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

The practice did not always provide care in a way that kept patients safe and protected them from avoidable harm. We have told the provider they must take actions to provide safe care and treatment.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There was some variation in people’s experience in the learning culture of the practice. For example, we received 560 responses through Give Feedback on Care from people who use the service for this assessment. Some people told us that although they felt they could make a complaint or suggest improvements they did not “have faith” that the practice would use their feedback fully. Others told us they had not made complaints to the practice because they didn’t feel they would be acted on appropriately.

We collected feedback from a variety of clinical and non-clinical staff. From these responses, we found that lessons learnt from significant events or complaints did not always result in changes that improved care for others. For example, some staff said that learning from incidents, complaints and other feedback was not shared with them. Other staff told us about changes that had been made in response to learning from significant events, complaints, and other feedback. However, the practice did not always review the changes made to make sure they were effective. Additionally, while the practice recorded significant events and complaints and identified causes for them, there were reoccurrences of some types of events, meaning common themes had not been addressed effectively. For example, missed actions from correspondence received or missed or delayed referrals. Staff were not always supported to be able to implement any changes effectively.

The practice monitored and reviewed safety using information from a variety of sources and there was a system for recording significant events and accidents. The practice had recorded 52 significant events in the year leading up to our inspection. However, not all staff knew how to identify and report a safety incident or accident, such as a needlestick injury, and the provider did not always identify and act on learning from them. We also saw that there was a system for recording national safety alerts, across both practice's sites, including recording the actions taken in response to them. However, as part of this assessment, we conducted searches on the practice’s clinical system and reviewed a selection of patients records and found that the practice did not always respond to safety alerts to protect patients affected by them from avoidable harm. For example, we found 360 patients who were prescribed a Sodium-glucose Cotransporter-2 (SGLT2) Inhibitor. We looked at the records for 4 of these patients and found the practice had not informed 3 of them of the risks associated with taking this medicine. The practice responded to our feedback and planned to inform the affected patients and ensure patients prescribed these medicines in the future are informed of the risks.

Staff had the information they needed to deliver safe care and treatment. Individual care records, including clinical data, were written, in line with current guidance and relevant legislation. However, feedback from a variety of clinical and non-clinical staff referred to inappropriate staffing levels at the practice to support safe systems, pathways, and transitions for patients.

For example, systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment were not always effective because of staff workloads and capacity. During our searches of the practice’s clinical system and review of a selection of patients records we found that referrals to specialist services were documented and contained the required information. However, systems to monitor delays in referrals were ineffective and while there was an approach to the management of test results, these were not always handled in a timely manner. The practice’s plans to manage backlogs in administrative tasks, such as summarising records and coding, whilst also processing workflow coming into and leaving the practice, such as letters from A&E and death notifications, were not effective. In response to our feedback, leaders told us about actions they had taken to review patients’ records, systems, and staffing matters, including reviewing correspondence that was waiting to be processed and taking the requested actions.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

The practice held appropriate emergency medicines and equipment. However, the practice did not show they carried out weekly checks at both sites, in line with the practice’s Emergency Drugs Monitoring Policy, to make sure emergency medicines and equipment were always available and safe to use if there was an emergency. During our site visit, we found the defibrillator at Larksfield Medical Centre was stating ‘low battery’, which the practice had not identified, and the emergency medicines and equipment at both sites were kept in a way that meant the practice would not know if a medicine or item of equipment had been removed. The practice responded immediately to our feedback to replace the battery in the defibrillator and place tags on the emergency bags to identify if they had been opened. The practice did not provide evidence 16 of the 45 staff working at the practice had completed the required appropriate training in basic life support. However, most reception staff had completed training in sepsis awareness. Sepsis, sometimes called blood poisoning, happens when your body overreacts to an infection and starts to damage itself. Symptoms can be difficult to spot, and sepsis can be life-threatening. Therefore, it is important that staff can recognise and act on symptoms.

Feedback from a variety of clinical and non-clinical staff, generally indicated that they had the equipment and facilities required to perform their roles.

Various health and safety risk assessments had been carried out. However, the provider had not acted on all recommendations from them. For example, the practice had taken most of the actions recommended in the fire risk assessment completed in May 2023 for Larksfield Medical Centre, for example additional signs had been put up and cleaning and consumable items had been moved to a safer storage area. However, the practice had not replaced or updated all the fire action notices and we did not see general emergency evacuation plans, including for people with limited mobility. However, the practice told us that they encouraged patients who had reduced mobility to ask when booking their appointment to have their appointment in a downstairs room, and there were posters to inform patients of this.

Weekly tests of the fire alarm and emergency lighting systems had been carried out at Larksfield Medical Centre. Three fire drills at Larksfield Medical Centre had been completed in the last year and the practice had identified and acted on learning from them. However, the practice did not provide evidence all staff had completed the required training in fire safety, a recommendation in the Fire Risk Assessment completed for Larksfield Medical Centre in May 2023. For the Arlesey Medical Centre site, leaders told us the fire risk assessment was held by another service who worked from the same building. Leaders could not provide us with a copy of the assessment. Following our feedback, leaders contacted the other service immediately to ask for a copy. Records showed fire drills and tests of the fire alarm system were completed at the site in Arlesey in partnership with the other services using the building. The Fire Evacuation Plans for both sites lacked clarity, and the plan for the Arlesey Medical Centre site, which had been due to be reviewed in December 2023, was not complete or relevant for the site. The practice responded to our feedback and reviewed the plans, however, further changes and updates were needed. Leaders did not provide a Legionella risk assessment for the Larksfield Medical Centre site when we asked for one. The most recent risk assessment for the Arlesey Medical Centre site had been completed in September 2021, with a recommended review date in September 2023. There was no evidence the risk assessment had been reviewed. We could not be sure the practice had taken actions to manage or reduce any risks relating to Legionella at the Larksfield Medical Centre site.

We received 560 responses through Give Feedback on Care from people who use the service for this assessment. For those patients who had been able to get an appointment, positive experiences were reported in their interactions with staff. Clinical staff were described as fantastic, kind, efficient, friendly, helpful, caring, and thoughtful. Others noted reception staff were warm or pleasant, and they tried their best to help. However, several people described negative interactions, citing clinical staff who were rude or patronising, and reception staff who were rude, cold, unmoving, dismissive, or unhelpful. This often was in relation to trying to make an appointment. There were also general comments about poor attitudes and a lack of care. Some comments described issues with staffing at the service, both in terms of the numbers and type of staff available. People told us about insufficient numbers of staff to serve the needs of patients. Some felt a lack of administrative staff contributed to difficulties making appointments. Others felt the lack of appointment availability was due to not having enough doctors working at the practice. This often resulted in seeing a different clinician other than a GP, for example, several comments noted appointments with pharmacists, health care practitioners, or a paramedic. However, they were often not able to provide the treatment required such as prescriptions, resulting in the need for a further appointment. People often attributed the insufficient numbers of staff to increasing demand on the service due to the growing patient list.

A variety of clinical and non-clinical staff also told us they had spoken up about concerns they had about the staffing levels and skill mix within the practice. They told us about their frustrations around not having enough non-clinical staff to manage the workload in a timely manner, and senior clinical staff having the capacity to support other members of the team whilst managing their own clinics and on-the-day appointments. During the inspection, we found that the practice had a programme of learning and development. For example, staff had access to online training. However, not all staff we spoke with had protected time to complete mandatory training or were supported to undertake learning and development activities. Some staff also said that they had access to appraisals and spoke about the support they gave to each other, as well as regular supervision. The provider told us about actions they were taking with regards to staffing matters, including a review of the staffing rota, staff recruitment and retention.

During our site visit, we looked at the staff files for 2 non-clinical and 5 clinical members of staff who had started working at the practice in the last 18 months. Recruitment checks were mostly completed, for example all 7 staff had a suitable DBS check. However, there was no employment history for 1 of the clinical members of staff, no check of professional registration for another member of clinical staff, and references had not been obtained in line with the practice’s Recruitment Policy and Procedure for 2 of the clinical members of staff. The practice had an Induction Policy and various tools for planning and recording staff inductions. However, of the 7 new members of staff whose records we looked at, we did not see records of inductions for 3 of the clinical members of staff. The practice did not evidence effective systems for making sure all staff worked safely, competently, and effectively, and to identify and address any concerns or areas for professional development. For example, not all staff had access to regular appraisals or one-to-one reviews or supervision. The provider did not evidence appraisals had been completed with 7 members of non-clinical staff and 5 members of clinical staff who, in line with the practice’s Appraisal Policy, should have had an appraisal. We also did not see evidence of one-to-one meetings or supervision had been carried out with 6 clinical and non-clinical members of staff once probation reviews had been completed.

The practice carried out infection prevention and control (IPC) audits at both sites. However, the provider had not always acted on issues identified in them, for example the monthly audits completed for Arlesey Medical Centre identified recurring areas needing attention, and during our site visit we saw the practice did not have all of the sharps bins required for the safe disposal of sharps, for example after giving certain injections, at Arlesey Medical Centre.

The UK Health Security Agency (UKHSA) have produced guidance setting out which diseases staff should have immunity against to help protect staff, patients, visitors and the public from harm. Although the practice had a system for recording when staff had provided evidence of immunity against various infectious diseases, the provider was not always aware of staffs’ immunity status or had put risk assessments in place to help to protect staff, patients, visitors, and the public from harm. Leaders did not provide evidence that 7 clinical and 4 non-clinical members of staff had completed appropriate training in IPC, and training records provided for this assessment showed a further 3 members of staff were overdue this training.

There were references to issues around medicines in the Give Feedback on Care we received from people who use the service for this assessment. These largely related to being unable to access prescriptions or that they were not handled in a timely way. People also felt they did not have regular reviews of their medicines, or medicines did not get renewed, appropriately. This was usually related to wider issues around access and being unable to contact the practice. Similar concerns had been raised by patients through the practice’s patient participation group (PPG).

The practice had processes for monitoring patients’ health in relation to the use of medicines and handling requests for repeat medicines. Our searches on the practice’s clinical system and review of a selection of patients records showed that the practice had recorded 1,323 medicines reviews had been completed in the 3 months leading up to our inspection. We looked at the records of 3 of these medicines reviews and found medicines had been reviewed appropriately. However, through our other searches, we noted medicines were sometimes prescribed without the patient having up-to-date monitoring and reviews. This included patients who were prescribed high-risk medicines that require monitoring because of the risks associated with taking the medicines. We found patients prescribed Methotrexate, a medicine used to calm and control the body’s immune system, to stop or slow the disease process in inflammatory conditions, such as rheumatoid arthritis, had been monitored in line with national guidance. However, 3 of the 10 patients prescribed Lithium, a medicine used to help people who have mood disorders, had not had all the recommended monitoring, in line with national guidance.

The practice had effective systems for recording, controlling, and monitoring blank prescriptions and kept them securely in ways that prevented their unauthorised access or use. Some staff at the practice were authorised to administer some medicines to some patients through using Patient Group Directions (PGDs). A PGD provides a legal framework that allows specific registered health professionals to give a named medicine to certain groups of patients, without the need for an appropriate clinician to issue individual prescriptions. To make sure PGDs are used safely, staff who have the skills and knowledge to give the medicine safely sign the document, which is then signed by the person responsible for its use who authorises the staff listed to use it. Although the PGDs we looked at for this inspection were all in date and had been authorised appropriately, the practice did not have a way to ensure names could be added to the list after the authorising person had signed the document.

The practice’s systems for ensuring medicines were stored in ways that maintained their safety and effectiveness were not always effective, such as, medicines requiring storage in a fridge. Records provided by the practice showed gaps in recording checks of fridge temperatures. On occasions when temperatures had been recorded, they were sometimes outside the acceptable range. There was no evidence the practice had identified these and taken appropriate actions in a timely way in response to them. The practice responded to our feedback, took actions, and described new systems they planned to implement to make sure medicines requiring storage in a fridge were safe and effective to use. During the inspection, the practice did not demonstrate that there were effective systems in place to monitor and ensure the members of staff at the practice who were non-medical prescribers worked competently and prescribed medicines safely for people using the service, in line with national guidance.

The practice had taken steps to ensure appropriate antimicrobial use to optimise patient outcomes and reduce the risk of adverse events and antimicrobial resistance. In response to our feedback, leaders told us about actions they had taken to review patients’ records, systems, and staffing matters, including describing new systems they planned to implement to make sure PGDs were completed appropriately in the future and the monitoring of the prescribing competence of non-medical prescribers.