Updated 10 October 2024
We carried out a focused assessment on 15 October 2024. At our previous inspection in April 2024, the provider was rated Good overall and in all the key questions. However, there was a breach in Regulation 17 Good Governance. This assessment was to follow up the breach. At our previous inspection we found the provider reviewed and investigated incidents and complaints and recorded actions taken. Medicines management reflected current and relevant best practice and professional guidance. Patients' medicines were appropriately prescribed in line with the relevant legislation, current national guidance, or best available evidence. Patients' needs were assessed using a range of assessment tools to ensure their needs were reflected and understood. There were effective approaches to monitor patients' care and treatment and their outcomes. Leaders and staff were alert to experiences and outcomes that could disadvantage different groups of people using their services. There were clear governance, management, and accountability arrangements in place. However, the provider was not working to their Prescribing and medication policy and prescription stationary was not being tracked in line with NHS guidance. There was no policy for staff to follow for Patient Specific Directions (PSD). At this assessment we found that processes had been reviewed and changed or improved. We saw evidence that systems and processes were working as intended. There had been a collective approach to ensuring that improvements within the practice were sustainable. Prescription tracking was changed and included individual script numbers which were tracked throughout the practice. The changes were discussed with staff at a practice meeting. There were weekly audits to ensure the new system was working as intended. We found the provider had made the decision to no longer use PSD's and that only nurses would administer vaccinations. The Prescribing and medication policy had been updated.