We carried out an announced review at Newtons Practice on 5 July 2021.
Following our previous inspection on 9 July 2019, the practice was rated Good overall and for providing effective, responsive, caring and well-led services but requires improvement for providing safe services.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Newtons Practice on our website at www.cqc.org.uk
Why we carried out this review
This review was a follow-up review of information without undertaking a site visit inspection to follow up on:
The outstanding breach of regulation 12 Health and Social Care Act (Regulated Activities) Regulations 2014; Safe care and treatment:
The provider did not ensure the proper and safe management of medicines. In particular, they had not ensured patients prescribed high risk medicines received blood tests in line with national clinical guidelines.
We also found that safety alerts and the actions to respond to them were not always documented
The provider was also asked to review and improve the recording of authorisations on patient group directions (PGDs). A Patient Group Direction (PGD) is a written instruction for the administration of medicines to groups of patients who may not be individually identified before presentation for treatment. For example, seasonal and other types of vaccination.
How we carried out the review
Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our reviews differently.
This review was carried out in a way which enabled us to spend no time on site. This was with consent from the provider and in line with all data protection and information governance requirements.
This included:
- Conducting staff interviews using video conferencing
- Completing clinical searches on the practice’s patient records system and discussing findings with the provider
- Reviewing patient records to identify issues and clarify actions taken by the provider
- Requesting evidence from the provider
Our findings
We based our judgement of the quality of care at this service on a combination of:
- what we found when we inspected
- information from our ongoing monitoring of data about services and
- information from the provider, patients, the public and other organisations.
We found that:
- The practice provided care in a way that did not keep patients safe and protected them from avoidable harm. For example, high risk medicines were not always monitored in accordance with national guidelines.
- The practice had a system to record alerts on medicines, medical devices and medicine supply issues. This allowed the practice to track their responses to these alerts where appropriate.
- Staff were supported by up to date PGDs. However, we found that not all of the PGDs had been signed by all of the staff prior to the sign off by the authorising manager. There was no system to revisit this procedure when new staff signed the authorisation sheet.
We found one breach of regulations. The provider must:
-
Ensure care and treatment must be provided in a safe way.
The provider should:
The provider was also asked to review and improve the recording of authorizations on PGDs
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care