Addison House - Haque Practice Also known as Addison House Surgery

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

We issued the prover with an action plan request following findings of some improvements required by the practice for breaches of Regulation 17 Good overnance of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We identified that there were some shortfalls in the management of safety alerts. We saw they were not always actioned in an appropriate time frame and this meant patients could be at a potential risk of harm. We saw a safety culture that was open and staff felt able to raise concerns. We identified areas where the provider should submit statutory notifications and the provider agreed to submit the required notifications which had not been received. We found the processes surrounding emergency medicine and fridge stock monitoring could be strengthened and the provider had begun to address these areas following our assessment.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Leaders told us they felt able to raise concerns and had learning shared in meetings. Staff we spoke with, could not always tell us recent significant events occurring at the practice. We identified that significant event learning analysis processes could be strengthened.

There was 9 significant events the provider told us had been completed within the previous 12 months. Of these, we saw there had been 4 repeated confidentiality breaches and we saw no evidence that there had been learning demonstrated or that staff had been re-trained in confidentiality. We saw 1 incident of police involvement due to aggression towards staff. The provider had not submitted the statutory notification required. The practice told us they would submit this notification which was not received. There had been 19 complaints since August 2023 sent to the practice. Of these, 7 complaints were about access, and the remaining complaints were about care and treatment. We saw complaints were investigated and the provider would respond to the person. There was not always escalation details for the Parliamentary and Health Service Ombudsman to each complaint response.

The provider worked with local care homes and we saw that the care home would inform the practice when a patients medicine review was due. There was also a dedicated telephone line for care homes to call the practice to obtain clinical advice, book appointments and discuss medicine queries or changes. However, care homes fed back poor response times by the practice. For example. care home staff told us a non prescribing clinician would undertake home visits and exampled occasions whereby they needed to back to the practice for a prescription to be actioned. The care homes told us this could delay prescriptions for up to 5 days. Additional care home feedback was there could be long delays chasing antibiotic prescriptions over hours and days for the correct prescription. An example given was a peg fed patient who had been prescribed Co-Amoxiclav tablets with no directions if this could be crushed to be administered through the peg. We were told a request for an alternative form of medicine had been declined. Other feedback we were told about included incorrect epilepsy medicine prescriptions being sent to care home residents.

Patients identified as frail, vulnerable and carers for others were given direct access to the practice and were overseen by a dedicated care coordinator, frailty team and social prescriber. Patients who required medicines to be given covertly did not always receive mental capacity assessments and the provider process could be strengthened. Medicines such as inhalers were sometimes prescribed without any consultation or communication for a new dosage and asthma reviews were not always completed prior to a prescription being issued.

Staff told us that there were 160 children on the safeguarding register and 60 adults, however, the practice safeguarding registers showed 251 Adults and 317 children listed. The risk of not having a clear oversight of safeguarding registers meant we could not be wholly assured effective systems, processes and practices to make sure people are protected from abuse and neglect. were embedded. Not all staff had completed the required safeguarding training for their role. The practice showed us a training matrix where we saw a GP who was out of date for safeguarding training. We spoke with 9 staff members who were able to demonstrate how they would raise a safeguarding concern and what safeguarding concerns were.

Partners told us there were regular meetings to discuss safeguarding concerns and meeting notes were taken. We were told that staff meetings would be used to share this information. We spoke to 5 staff who could not always recount safeguarding examples and we could not be wholly assured that all staff were aware of recent safeguarding concerns raised. Safeguarding information was reviewed by a GP and reported within the patient records. The practice used coding methods to identify vulnerable patients. National guidance for safeguarding measures should include parents of the child being correctly coded as well as the child. We reviewed records and could not always be assured coding was being assigned correctly to parental records.

We saw no evidence of safeguarding register corroboration . We could not be assured there was always accurate data for safeguarding and this was discussed with our GP specialist advisor during our practice interview. We discussed with the provider ways of strengthening safeguarding process and the practice told us they would look to make changes. The provider did have designated safeguarding leads and administrators and staff told us that anyone listed on the registers would have a flag against their records. However, we noted not all relatives living with that person were also flagged on the safeguarding register. The practice told us that they would review these records to ensure corroboration of registers and patient flags were accurate.

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.

There was a fire risk assessment completed by Essex Fire Service in 2022 and there was no evidence of an action plan for medium risk actions. When the provider was asked for this, they showed a fire risk assessment form they had completed for Barbara Castle site 31 July 2024 and had not stated any of these risks. Addison House site had completed their own fire risk assessment and had not stated any risks identified within the Essex Fire Service fire risk assessment. We spoke with the local fire service who told us they would be visiting the provider to provide some information on how to complete their risk assessments. We observed parts of both buildings requiring repair, for example, walls and floors. The provider told us the internal repairs were the landlord responsibility, however, the landlord provided us with details the practice had an internal leasing contract, making them responsible for the internal maintenance.

Legionella bacterial test report dated 13 June 2024 had seen a result of 300 c/ful (colony forming units) and there was no action plan or risk assessment. The provider addressed this immediately when we told them about this finding. There were external contractors from Essex County Council who were responsible for the facilities and equipment and the provider showed us evidence of them asking for repairs to be completed and being told no.

The practice told us that staffing were competent to do their roles. However, when we reviewed staff training records, we identified not all clinical staff had completed mandatory training. Staff told us during our assessment that there was a lack of GP presence at the Barbara Castle site and most days there was no GP on site. The provider showed us a rota and the GP allocation showed that there were days when there was not a GP. We asked the provider if in the event of an emergency a GP from the main Addison House site would attend to support the advanced care practitioners and we were told "The only clinical emergency would be a cardiac arrest and there are advanced nurse practitioners and paramedics there. healthcare should move with modern practice in 2024". We discussed the importance of GP oversight to advanced clinicians and supporting them is essential to meeting regulations of good governance.

There was a high locum use at the practice and GP locum packs were used. On the staff training record, we found that not all locum staff had completed mandatory training. There was a clinical supervision process in place and staff would have appraisals and supervisions. There was succession planning and at the time of our assessment, there were 2 staff on a management course, new prospective GP partners identified and 1 nurse completing a masters programme. Staff inductions were completed and staff were supported during commencement of employment. We reviewed 5 random staff recruitment files and found 3 of them did not have signed contracts, 1 file had only 1 reference. All staff had up to date disclosure and barring checks. There were some gaps on staff immunisation records held within the recruitment files, although the practice had a list held centrally for these.

We identified many areas of infection prevention and control concerns during our on site inspection. These included damaged walls, thick dust, cracked pathing walkways that were a risk to staff and patients. We also identified areas of concern with stained walls, carpets in clinical areas and general dirt during walk arounds. The provider told us they had contacted the landlord for the properties to escalate these concerns and also contacted the external maintenance and cleaning contractors to raise concerns previously and showed us evidence where they had not been actioned despite provider requests. The emergency medicines cupboard had loose medicine vials in a plastic uncovered container and we found 8 loose aspirin tablets. We also found 2 silver nitrate boxes labelled with patient details dated 2022. We discussed these findings with the provider who rectified this immediately and completed an in house audit of the emergency medicines and emergency grab bags.

The provider was working with the local integrated care board and looking at alternative options available to improve infection prevention and control. There were processes within the staff leads for infection prevention and control that could be strengthened. For example, record keeping and detailed documentation of all actions taken. For example, we found slips of hand written notes between maintenance and the practice that were loose and without context to wider concerns raised by the practice leadership team with external contractors. The medicine fridges had data loggers for temperature readings. We spot checked stock listed and found Shingrix vaccine was listed on stock control sheets as 4 when the actual count was 25. Boostrix vaccine had been listed on the stock control sheets as 9 when the actual stock we counted was 33. We discussed this with the practice who told us they were reviewing their stock control processes with their suppliers for online account synchronisation of stock.

Our clinical searches identified 48 people were prescribed Methotrexate. Of these, 4 patents were overdue monitoring. We sampled 5 patient records and saw 2 patients were under hospital monitoring and had recently been changed from oral tablet to injection form. We did not see any shared care protocol for the GP. We identified 1 patient had not received blood testing since October 2023. We also identified as per the 2020 Medicines and Healthcare products regulatory agency (MHRA), there was no day day of administration noted on the 5 patient records we reviewed. We asked the provider to review all patients prescribed Methotrexate. Thee provider told us about historic challenges of patient recalls for diabetes. We identified 23 patients who had a potential missed diagnosis of diabetes and had not received blood monitoring within the national guideline of 2-12 weeks. We discussed strengthening patient recalls with the provider. We identified 381 people with a potential missed diagnosis of chronic kidney disease 3, 4 or 5 and found the provider was not following national guidance or following up with patients. We asked the provider to strengthen this process.

We identified through our clinical searches 1 patient who was prescribed Metformin with eGFR <30. This patient had low blood test results for eGFR in 2022 and further more in March 2024. We asked the provider to follow the MHRA alert and stop the medicine on 30 July 2024 and the practice confirmed this medicine had been stopped on 1 August 2024. A review of the 2014 MHRA alert for Citalopram showed 18 patients at risk and the risk varied with age and co-medications. The risk was mostly for rheumatology patients going into an arrhythmia with Citalopram of Hydroxychloroquine. A random sample of 5 patient records showed none of the patient medicine reviews had identified this significant MHRA risk and no record demonstrated the practice had completed heart monitoring of these at risk patients. We then reviewed other MHRA alerts and discussed these during our GP interview. We identified the GP was unaware of recent MHRA alerts of the use of Epimax cream, Finasteride or Montelukast prescribing. We asked the provider to review their processes for MHRA alert monitoring.

We saw 58 patients prescribed an Aldosterone antagonist monitoring medicine and 28 patients were overdue monitoring. The provider immediately reviewed all these patients following our clinical searches. The practice would follow up patients due monitoring and of a sample of 5 patient records, 1 patient had not been reviewed for over 12 months. The provider told us due to the patient demographic types, recalls for patients could be challenging. However, the provider was working with the local integrated care board to optimising patient compliance and using a proactive approach to encourage patients to attend monitoring appointments. We discussed with the practice of designing a protocol for non- responder patients to patient recalls.