Bromleag Care Practice

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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 found the service was providing safe care. There were systems to ensure patients were safeguarded from abuse. The provider demonstrated learning from complaints and significant events was shared with practice staff. We also found some areas for improvement. Patients with chronic kidney disease were not always coded as such. Patients aged over the age of 65 prescribed a non-steroidal anti-inflammatory drug (NSAID) were not always prescribed a proton pump-inhibitor (PPI) in line with best practice guidance. The provider did not hold salbutamol as part of their emergency medicines stock. Leaders told us attempts had been made to improve staffing levels, however staff reported there was insufficient staff working in the service. A risk assessment had identified a high level of risk in relation to legionella. The service was not able to provide details of any remedial action that had been taken to address this risk.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We asked staff working in the care homes associated with the practice whether incidents were shared with care home staff. We received mixed responses with some staff telling us lessons learned were shared with them and others saying they were not aware of any incidents relating to their care home.

All of the staff we spoke to were aware of how to raise incidents. Staff we spoke to detailed how learning was shared with them on both an individual basis, and organisation wide. Leaders detailed how they supported the process, and staff as required.

There was a system for recording and acting on significant events and incidents. There were adequate systems for reviewing and investigating when things went wrong. The service learned and shared lessons, identified themes and took action to improve safety in the service. The service learned from external safety events and patient safety alerts. The service had an effective mechanism in place to review alerts and disseminate them to members of the team as required.

Staff working in care homes told us they found it easy to contact the practice. Routine ward rounds were scheduled every 2 weeks, and care homes told us they could contact the practice for urgent appointments, where patients were seen on the same day. Most care homes told us there were sufficient ward rounds, however some staff reported their ward rounds could be missed if their assigned GP was on leave, off sick, or the ward round fell on a bank holiday. In these cases, there were not always systems in place for a different GP to carry out the routine ward rounds.

The staff we spoke to were all aware of care pathways, including referrals and taking on care of those patients who had been discharged from other services. Leaders at the service shared relevant information with staff in team meetings.

Partners had no specific feedback on this area.

The service had processes in place to ensure that referrals and discharges were managed quickly. There were also systems in place to ensure that where care was shared, information was shared between organisations, for example where blood tests and monitoring were undertaken by another provider.

We found no concerns regarding people’s experiences of safeguarding.

The practice had a safeguarding GP lead who was allocated time to review patients where there were safeguarding concerns. Staff at the service to whom we spoke were aware of how to make safeguarding referrals and knew the identity of leads if further advice was needed. Leaders told us how advice was available to staff as required.

Partners did not raise any concerns regarding safeguarding.

The service worked with other agencies to support patients and protect them from neglect and abuse. Staff took steps to protect patients from abuse, neglect, harassment, discrimination and breaches of their dignity and respect. The provider carried out staff checks at the time of recruitment and on an ongoing basis where appropriate. Disclosure and Barring Service (DBS) checks were undertaken where required. (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable). All staff received up-to-date safeguarding and safety training appropriate to their role. They knew how to identify and report concerns.

Care home staff reported a person-centred approach from the practice. We were told GPs took the time to discuss concerns with patients and, where appropriate, their families.

Leaders told us that staff were informed in managing risk, and that standing items such as safeguarding and incidents were discussed at all meetings. Staff reported that they were included in risk management, and that they were happy to report when things went wrong.

There were process in place for risks to be discussed with all staff. We observed the service was equipped to respond to medical emergencies, including suspected sepsis, and all equipment was regularly checked. The practice had protocols in place to manage the prioritisation of patients. Staff had completed basic life support, anaphylaxis, and sepsis training.

Staff at the service were aware of where all emergency equipment was stored. Leaders at the service were able to detail the policies and procedures that were in place to ensure that the environment was safe.

The service had administrative offices at its main site, but all clinical interactions took place at the residential homes at which patients were based. The main administrative hub was fit for purpose. All equipment had been checked and calibrated as required.

The service had undertaken a full range of risk assessments to ensure that the environment was safe, including premises, and health and safety. Where there was learning from these risk assessments, we saw that the service acted quickly to address any specific issues raised.

Some homes said they sometimes missed out on ward rounds when staff were off sick or on leave. Ward rounds were not always covered. However, care could be accessed when patients had urgent requests through the duty system. The practice responded that care homes were informed where the allocated ward round day may need to be changed or cancelled. Care homes were advised to contact the practice via telephone if an unwell patient needed to be added to the duty list.

Leaders told us that they had worked hard to recruit to posts. Staff who worked at the service told us that staffing at the service was insufficient. They told us that there had been a number of vacancies, and also that even at complement there were insufficient staff. They reported that this was particularly the case given the needs of the practice population, which was higher than that of most general practice services.

The service had a clear induction program. Staff told us that the induction when they started at the service had been helpful. Staff also received 1 to 1 and team support from managers and received appraisals.

We identified no concerns regarding people’s experience of infection prevention and control.

Leaders told us they worked with residential homes at which services were based to ensure the premises were suitable for clinical care. Staff told us that they were provided with infection control equipment when they were onsite.

The service had no clinical rooms at the time of the assessment, although the service was looking at the possibility of taking on a clinical room at their base for services such as cervical screening. All non-clinical areas at the base were clean.

The provider mostly ensured that facilities and equipment were safe. There were systems for safely managing healthcare waste, and the provider carried out appropriate environmental risk assessments. However, the location at which the service was based had undertaken a Legionella risk assessment in January 2024, which had found the level of risk to be high. At the time of the assessment, the service was not able to provide details of any remedial action that had been taken to address this risk.

Our clinical searches found there were patients over the age of 65 who were prescribed a non-steroidal anti-inflammatory drug (NSAID) without a proton pump-inhibitor (PPI). The lack of PPI exposed patients to the risk of side effects. Salbutamol inhalers were not available in the service's medicine packs, used by clinicians to take to site visits. Without these inhalers, the service would not have been able to manage acute exacerbation of asthma, in the absence of an inhaler held by the patient.

The leaders explained there was a process for monitoring patients’ health in relation to the use of medicines including high-risk medicines (for example, warfarin, methotrexate and lithium) with appropriate monitoring and clinical review prior to prescribing. Staff told us they had a system in place to ensure the safe prescribing of patients' repeat medicines. Staff explained the systems they used to monitor vaccines, emergency equipment and medicines. However, as part of our assessment, we reviewed a number of clinical searches to ensure that medicines were managed in line with best practice. We asked leaders about one specific instance. We found that there were a number of patients who potentially had a missed diagnosis of chronic kidney disease (CKD) but this was not recorded on the clinical record. We reviewed 5 of these records, and in each case the patient should have been coded as CKD stage 3. Two of the clinical leads were asked about this in an interview. They said that because all of their patients were in care homes, most of them would have CKD, and that they were monitored regularly so coding was not required. However, they were not able to provide a locally agreed protocol for patients with this specific condition not being coded as such. The coding allows for structured review in the clinical records, which was absent in these patient records.

We observed that some medicines at the service were stored safely, and that access was restricted to specific staff. Staff had the appropriate authorisations to administer medicines (including Patient Group Directions). There was a process for the safe handling of requests for repeat medicines and evidence of effective medicines reviews for patients on repeat medicines. The practice had most emergency medicines in place. However, none of the emergency medicines packs that clinicians took on site had salbutamol in place. The service told us that they were waiting for an order following the expiry of previous inhalers. On the basis of the lack of inhalers, the service would not have been able to manage an acute exacerbation of asthma if the patient did not have the medicine already. There was medical oxygen and a defibrillator at each site and systems to ensure these were regularly checked. Administrative staff at the hub site were unaware of how the oxygen cylinders worked, which may have impacted their ability to check these oxygen cylinders as part of the system for checking emergency equipment.

The practice had a system in place to monitor the fridge and clinical room temperatures for the safe storage of medicine, this was supported by a policy which had been recently reviewed. The practice had put systems in place to monitor the safe administration of patients’ medicines, the prescribing of repeat medicines and the monitoring of emergency medicines. The provider did not stock-controlled drugs.

As part of our inspection a number of set clinical record searches were undertaken by a CQC GP specialist advisor. These searches were visible to the practice. We found that monitoring was appropriate in most cases. However, in some instances this was not the case. For example, we reviewed management of patients where non-steroidal anti-inflammatory drug (NSAID) had been prescribed. There were 43 occasions of a total of 297 where patients over the age of 65 were prescribed an NSAID without a proton pump-inhibitor (PPI). We reviewed 5 of these records in more detail. None of the records contained documented reasons why a PPI had not been prescribed, and they should have been in place. The lack of PPI exposed the patients to adverse effects, particularly in the case of 1 patient who had a history of ulcer.