Danbury Medical Centre

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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 assessed a total of 2 quality statements from this key question. We have combined the scores for these areas with scores based on the rating from the last inspection, which was good. Our rating for this key question remains good. At this assessment we found that leaders had utilised a consultant and had recently implemented new systems, practices, and processes to help keep people safe, but these were in their infancy. The practice had not consistently learned from significant events; the referrals process was not always effective and they did not always have safe systems to manage medicines, however, the practice immediately responded to identified concerns and took action to address them. They compiled an action plan during the assessment and provided assurance that they were making improvements and measuring these to ensure they were working to provide safe care and treatment. The practice undertook regular audits to improve outcomes for patients.

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.

The national GP patient survey carried out from January to March 2024 found 78% of respondents stated the healthcare professional was good at listening to them and 77% of respondents stated the healthcare professional was good at treating the patient with care and concern. In addition, 88% of patients had confidence and trust in the health care professional they saw or spoke to compared to the England average of 92%. The practice submitted their friends and family test responses for April 2024. Out of 820 patient’s responses 755 stated their experience of the practice was either very good or good.

Leaders and staff told us they knew how to identify and report concerns, safety incidents and near misses both internally and externally. They were able to discuss evidence of some learning and dissemination of information. They told us they had a new system for reporting incidents and had established a bi-monthly patient safety and quality meeting in March 2024 to review patient safety, risk, incident investigations and complaints. Staff told us they reported incidents and near misses but were not made aware of the outcome or of changes and learning as a result. Leaders told us there was a system for recording and acting on patient safety alerts, however we found this was not always effective. Action was taken by the practice to address this during the assessment. Leaders told us that complaints were responded to promptly and that a new complaints manager had been recruited. We found responses did not contain advice for patients to escalate their concerns. The practice took action to address this during the assessment.

The practice had a Central Alerting System Policy last reviewed in June 2024. However, the system to manage safety alerts was not always effective. We found that not all patients who may have been affected by a Medicines and Healthcare products Regulatory Agency alert, had been informed of the side effects of the medicines. The practice had compiled an action plan including a process for managing alerts and had started to address this during the assessment period. The practice had established a new management structure and a suite of meetings in March 2024, to identify, address and learn from patient safety concerns. Significant events were a standard agenda item at quarterly meetings where learning was discussed. However, we found certain events, such as referrals not being made, continued to occur across a 2 year period, indicating that the system was not effective and opportunity to improve had been missed. The practice had a duty of candour policy in place which was last reviewed in June 2023, and we saw that it was considered as part of the significant events processes.

The national GP patient survey carried out from January to March 2024 found patients were concerned about access to the practice. 21% of respondents stated it was easy to access the practice by telephone. This was an upward trend as in 2023 only 13% of respondents were positive. 24% of respondents found it easy to contact the practice via their website, compared to the England average of 48% and 20% found it easy to access the practice via the NHS app, compared to an England average of 45%.49% of respondents were satisfied with the overall experience of the practice. Compared to the England average of 74%. 78% of respondents stated the healthcare professional was good at listening to them and 77% of respondents stated the healthcare professional was good at treating the patient with care and concern. In addition, 88% of patients had confidence and trust in the health care professional they saw or spoke to compared to the England average of 92%. CQC received 8 complaints in the last 6 months. Access to appointments was indicated in 5 of these. The practice submitted their friends and family test responses for April 2024. Out of 820 patient’s responses 755 stated their experience of the practice was either very good or good.

We found that the referrals process was systemically ineffective, in that, GPs were not consistently ensuring referrals were actually sent. Staff told us there were less than 2.5 secretaries for 25000 plus patients which was insufficient to meet the demand. Leaders told us a team of GP assistants was being established to review tasks and referrals starting in August 2024. 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. Leaders told us they had shared care agreements on their new system for patients who were treated by secondary care.

Leaders told us they had regular multidisciplinary team meetings to discuss and improve outcomes for people with complex needs. The practice supported one care home for older people, the care home’s manager confirmed that staff attended the home weekly, responded promptly to their requests, and they had good lines of communication with the practice. Leaders told us they had established a duty hub to separate planned and unplanned care, with advanced clinical practitioners supervised by a duty doctor to triage on the day. Where required, appointments were made within 48 hours or on the day when necessary. A primary care network memory clinic had been established by the practice to enable faster diagnosis of dementia. Leaders told us this had been utilised by 14 additional practices and there was a clear and embedded process which led to diagnosis, where appropriate, within 6 weeks.

The practice had a referral policy reviewed 29 September 2023; however, this was not always followed. For example, it stated that regular audits of referrals would be carried out, shared at clinical meetings and minuted. During the assessment records we viewed did not demonstrate this was happening and staff told us referrals were not audited. Referrals were discussed in a meeting in May 2024, however a clear system to ensure GPs were generating them effectively was not in place. A document was reviewed which outlined referral procedures. The practice had a clear workflow standard operating procedure and told us a team of GP assistants were being set up to review tasks and referrals starting in August 2024. The practice had established a process to ensure patients had the relevant blood tests prior to their medication review being booked. They also had a system to reduce medication for patients who were not engaging until they had the necessary tests. The practice had a procedure whereby they reviewed a patient safety, support and insight system weekly for red flags which would indicate a medicine or long term condition review was overdue.

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

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

People had access to the dispensary team and were able to get their medicines from 8am to 1pm and 2pm to 6.30pm five days a week. People could order their repeat medicines in variety of ways and turnaround times were within 72 hours. Some people who required extra help with their medicines had them supplied in compliance aids (also known as blister packs). A delivery service was available to those people who could not collect their medicines. People receiving some skin preparations were not made aware of the flammable risk and were not provided with adequate information. This was addressed by the practice during the assessment.

Staff told us they received 1:1s every month and had an opportunity to discuss any concerns. They were positive about their working environment and found colleagues supportive and approachable. Pharmacy staff attended the patient Quality and Safety meeting. Staff reported incidents and near misses. It was not always clear from the new reporting tool what reflections people involved in incidents had undertaken and what actions had been taken to avoid reoccurrence. The pharmacy team worked closely with colleagues across the Integrated Care Board (ICB) and community pharmacy to support people to get their medicines when they needed them. All staff were given the opportunity to participate in relevant training and development sessions covering topics such as wound care, contraception, chronic obstructive pulmonary disease and diabetes. 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 patient’s repeat medicines. Staff explained the systems they used to monitor vaccines, emergency equipment and medicines.

The dispensary was clean, tidy and well organised with only authorised people having access. Medicines stocks were managed well, expiry dates checked, and appropriate checks of the dispensing process were in place. Not all emergency medicines were available, however, the practice addressed this during the assessment. The emergency medicines that were available were being checked regularly. Medical oxygen was available and stored appropriately. Medicines requiring cold storage were stored, monitored, and transported appropriately including vaccines. Stock controlled drugs were appropriately stored and checked regularly. Controlled drugs that had been returned for destruction were not managed appropriately and the practice would not have been able to tell if any were missing. Blank prescription forms (FP10s) were stored securely with restricted access but were not recorded adequately so the service would not be able to tell if any were missing. The practice took action to put processes in place to address the issues raised. Patient Group Directions (PGDs) were in place to allow nurses to give vaccinations without a prescription and these had been appropriately authorised for use within the service.

Standard operating procedures were in place for all the dispensary activities. There was a duty GP and a duty pharmacist every weekday to deal with urgent issues. The pharmacy team supported the management of long-term conditions within the practice which involved pharmacy technicians ensuring that all the required tests such as blood pressure or blood tests had been done before the annual medicines review by the pharmacist. The practice undertook 800 medicines reviews per month. When we undertook remote searches to ensure that all people on high-risk medicines had received the required monitoring for drugs such as methotrexate, anticoagulants and thyroid conditions we found that not all patients were recorded as having the essential tests done. The practice took action to address this. The practice had a system for recording and acting on drug recalls but not all safety alerts had been actioned such as ensuring people with skin creams that posed a flammable risk had counselling and an information leaflet given to them. This was addressed during the assessment. There was a process to review any uncollected medicines and inform the necessary staff and check on patients if necessary. When people were discharged from hospital the processing of the information was outsourced which had a turnaround time of 3-5 days.

The clinical searches found that not all patients had the required monitoring and there was some evidence the prescriber had not checked monitoring was up to date prior to issuing a prescription. An action plan was put in place by the practice to address these concerns and they took immediate action. A diabetes audit showed that people had not always received the follow up blood test required to diagnose diabetes. In response a flowchart was put in place in March 2024 to ensure clinicians appropriately followed up these patients. Asthma audits were being undertaken, for adults and children. The practice belonged to the Dispensary Services Quality Scheme (DSQS) and completed annual audits as part of this. Audits had included suitability of medicines within compliance aids which had led to changes in dispensing procedures. An audit looking at compliance with a weekly medicine for osteoporosis had led to people being counselled about how to take the medicine appropriately. Some people had been identified as not having calcium prescribed which had now been rectified. The outcome of another audit had implemented initiatives to reduce medicines waste. The NHS Business Services Authority medicines data in January to December 2023, which reviews hypnotic, multiple psychotropics and antibacterial prescribing results were either in line or better than the national average.