The Ecclesbourne Practice

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

During the inspection, we reviewed policies, spoke with staff, and undertook observations while on site. Although we found the provider had made improvements since the last inspection, there remained areas where the practice required improvement. For example, the practice did not have an effective process to manage safety alerts from the Medicines and Healthcare Products Regulatory Agency (MHRA), which was highlighted at the last inspection; there remained gaps in staff recruitment and training, and at the time of inspection, the provider did not have a structured process to monitor all clinical staff.  

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Feedback from staff and leaders demonstrated that the practice had a culture of identifying incidents and complaints, learning, and improvement. Staff told us they felt they could raise concerns and report when things went wrong. However, a part-time staff member told us that they often did not find out about changes within the practice, or they are informed by another staff member rather than the leadership team.

The practice had a significant events and complaints policy. Incidents were discussed during team meetings; however, the meeting minutes did not provide sufficient detail to determine the breadth of conversations and learning shared. From the sample of complaints we reviewed, we could not determine what action was taken or whether the practice had responded to the complainants. The provider told us they were aware the complaint dashboard had not been completed appropriately and had recently appointed a new practice manager who intended to follow up on each complaint. The practice had a policy to manage the significant event process, a log to record events and we saw evidence that incidents were discussed at practice meetings. However, the meeting minutes provided limited information, the event log also gave leadership limited oversight of the process and did not demonstrate the practice had determined whether the incident was likely to be repeated. These findings underscore the need for more comprehensive information in meeting minutes and event logs to ensure effective oversight and prevent incidents from recurring. During the unannounced inspection, we reassessed the practice’s complaints process to determine whether it was working effectively. We found that the practice manager had recorded and responded to complaints, and they were discussed during team meetings. We also revisited the practice's significant event process. The provider shared the write-up of two significant events that occurred after our inspection in March. We found that both incidents had a date when they would be discussed during a team meeting; however, there was only evidence of the practice team discussing one incident.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

Safeguarding policies and procedures were available and accessible to all staff. There were regular discussions between the practice and other health and social care professionals to support and protect adults and children at risk of significant harm. We found safeguarding training was provided at the appropriate level for non-clinical staff. However, three of the clinical team's safeguarding training certificates were unavailable on the day of the on-site visit. Following the inspection the provider forwarded the certificates for one of the staff members and provided evidence that the other staff member's training had recently expired, and they were booked to undertake face-to-face training in a few days. A GP partner's safeguarding training certificate remains outstanding. During the unannounced inspection, we found that the GP partner who previously had gaps in their training was up to date with their training requirements. However, we noted that the practice did not have the training certificates for all their locum doctors. For example, neither of the two locum doctors whose files we reviewed, had a record of mental capacity training which is required for all clinical staff. In addition, one out of two of the locum doctors’ recruitment files did not have proof of identity or previous employment references. The provider informed us that their locum doctors were sourced from an external agency which had not yet forwarded all their recruitment documents. The provider also told us they would open an account for their locum doctors to undertake their training using the practice’s internal training platform. We reviewed the practice’s safeguarding processes and saw that safeguarded patients were coded and discussed during multidisciplinary team meetings. We observed that the practice had a well-structured locum pack, a practical resource for new locums. This pack included essential information about the practice and local services.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

We observed that the practice was uncluttered, fire extinguishers were available. However, they did not have a paediatric pulse oximeter to detect if there was enough oxygen in the blood. We discussed this with the provider, and an order for a pulse oximeter was placed during the site visit. The practice did not have a health and safety poster in a visible location. During the unannounced inspection, we observed that the door to the staff kitchen, which contained the vaccine fridge, was not locked when the room was empty. Following the inspection, the provider provided evidence they had placed a sign on the kitchen door to instruct staff to lock the door after use. We also found an out-of-date (by one month) salbutamol nebuliser solution (used for the routine management of chronic bronchospasm unresponsive to conventional therapy and in the treatment of acute severe asthma) and chlorphenamine (relieves the symptoms of allergies) in the practice’s emergency medicines bag. The provider had boldly marked the packages to indicate they were out-of-date. Two days after the inspection, the provider provided evidence that they had obtained additional stock from a neighbouring site. We identified an unoccupied flat above the practice which contained patient records. The flat was locked and inaccessible to patients. The provider told us that the notes, which had been to the practice’s electronic system, were due to be collected by an external company.

The practice had a range of risk assessments and processes to ensure the environment's safety; for example, medical equipment was calibrated, and they had undertaken portable appliance testing to ensure equipment was fit for purpose and was in good working order. The provider evidenced that they had scheduled an external company to undertake remedial action identified in the fire risk assessment, which would take place in April 2024. We reviewed the practice's fire evacuation log, which listed the fire drills carried out in June and December 2023. On both occasions, the entries noted that high-visibility jackets were unavailable for staff, and a significant event was raised. However, it was unclear what action was taken to ensure the jackets would be made available. During the unannounced inspection, we reviewed the providers' premises safety processes, such as legionella testing, fridge temperature recording, weekly fire alarm testing, equipment calibration, PAT testing, and emergency medicine management. We found that the equipment at both sites was calibrated and had received PAT testing except for one electrical item at the Roding Valley Surgery. We queried whether the remedial actions identified in the practice's fire risk assessment, health and safety risk assessment and disability access risk assessment had been undertaken. The practice manager had completed most of the priority actions and told us they had to place the remaining actions (outlined in the fire risk assessment) on hold while they waited for funding from the Integrated Care Board. However, they had managed to acquire an evacuation chair, which was an outstanding action at the inspection in March. The practice did not use paper prescriptions. Prescriptions used were electronic and printed by the prescribing clinician when required.

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

We observed the practice and equipment used to be clean and hygienic. We noted that the clinical bins were not lockable, but the provider evidenced that lockable bins were on order.

The practice had an infection prevention and control policy (IPC), and staff had undertaken IPC training at the appropriate level. One of the GP partners was the IPC lead. They were trained in IPC and intended to undergo enhanced training for the role. The provider shared their latest IPC audit, which they had carried out two days before the inspection. Staff had received vaccinations appropriate to their role. We noted that the legionella testing was carried out by an external company every month and saw evidence that the regime was advised due to the type of plumbing at the practice.

The provider had comprehensive policies to govern medicines management, including prescribing high-risk medicines. It involved appropriate monitoring and clinical review before prescribing. The practice also had a suite of clinical audits and shared learning during clinical meetings. However, the practice did not have a structured process to specifically review the prescribing of their non-medical prescriber, who started at the practice in February 2024. In response to raising this concern, the provider told us that, in the future, they will provide monthly data on all clinicians' prescribing and present the information during clinical meetings to highlight good practices and ensure early detection of negative variations in prescribing. During the unannounced inspection, we identified that the provider had a backlog of over one thousand tasks being processed by administrative staff. We discussed this with the provider, who told us the list was worked through daily, and the administrators sent urgent letters to the pharmacist for immediate action. The remaining letters were visible to consulting clinicians. We cross-checked the referral list with patients’ consultation notes and found that the patients were managed appropriately. The management of safety alerts from the MHRA was a concern, as we discovered alerts relevant to general practice were marked as not relevant. The provider told us they were aware of this issue and planned to update their safety alert log with the correct information.

Our GP Specialist Advisor (GP SpA) carried out 12 remote clinical searches, most of which showed good practice and the management of treatment that reflected current and relevant best practice and professional guidance. Overall, the clinical searches yielded positive results; however, a few areas needed further attention. For instance, the GP SpA searched for patients prescribed more than ten prescriptions for benzodiazepines or Z drugs. Fifty-two patients were identified. The GP SpA looked at five records and found one patient was not informed about the risks associated with the medication. In addition, a search for missed diagnosis of diabetes showed that one pre-diabetic patient was not coded appropriately. The practice’s prescribing performance up to December 2023 showed they aligned with the local and national outcomes in most indicators. However, they were below the averages for the prescribing of three antibiotics. We discussed this with the provider who shared the practice's up-to-date data, which showed they achieved a 26% and 44 % reduction in prescribing two antibiotics in two consecutive quarters of the year. There was a slight increase in the remaining antibiotic, which the practice had developed an action plan to address and were monitoring closely. The provider was aware that the practice's uptake of child immunisation and cervical cancer screening was below the national average and had a process in place to educate and recall patients.