Ringmead Medical Group

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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 identified two breaches of the legal regulations. During the assessment we reviewed evidence remotely, spoke with staff, completed remote clinical searches of the practice’s clinical system and undertook observations while on site. We found the following: There was limited evidence that learning from significant events that occurred was shared within the practice and that changes resulted from the process. We were not assured that clinical tasks and correspondence were monitored or managed effectively because we found evidence of backlogs and did not obtain assurance the practice had oversight of this risk. The practice had processes to code vulnerable patients and a process to share information within the practice and with partners. Safeguarding training requirements followed national guidance. However, we found not all staff were trained to the correct level which posed the risk that patients would not always be safeguarded from the risk of abuse. We did not find evidence of effective processes to ensure premises were maintained and kept safe for both service users and staff. This concern involved multiple areas including fire safety and the risk of legionella being present. Recruitment processes did not ensure staff employed were safe and effective to carry out their roles. Infection prevention and control (IPC) processes did not ensure that service users were protected from the risk of unsafe care and treatment because the practice did not have effective systems to management risks including incomplete records of vaccination for staff, monitoring of consumable stock and specialist IPC training. There were ineffective systems and processes to monitor staffs’ compliance with training. Systems and processes to monitor the stock and expiration dates of emergency medicine and equipment were ineffective and operated inconsistently throughout the practice.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We asked the provider to share details of our Give Feedback on Care process with patients. A link was placed on the services’ website, and we received 35 pieces of feedback. None of the feedback shared related to this quality statement.

Staff we spoke with were able to provide examples of significant events they were aware of or had reported, and changes that had occurred as a result. However, we asked the practice to share a questionnaire with staff and we received 33 responses. These included mixed responses about whether staff felt leadership and management responded effectively to concerns raised. None of the responses directly raised concerns about safety or risks not being responded to and the answers indicated staff were able to raise concerns. However, we found a theme that concerns weren’t addressed in a timely manner and outcomes could be communicated more effectively and more openly or transparently.

The practice provided a log of the significant event activity (SEA) during the last 12 months. 29 SEA’s were recorded and we reviewed a sample of 3. We found SEA’s were recorded and investigated but found very limited evidence of how learning was shared throughout the practice. For example, only 1 set of meeting minutes we reviewed referred to a SEA and those contained minimal details about the incident. We found evidence that the practice had a process for staff to raise concerns both internally and externally. However, the evidence we reviewed did not consistently contain all the information staff may need. For example, not all documents contained details for the external Freedom to Speak Up Guardian. Our overall findings were that the practice did not have consistent and embedded processes which ensured staff could find the information required to raise concerns or that when incidents were reported, learning was identified and resulting changes were communicated effectively throughout the practice.

We asked the provider to share details of our Give Feedback on Care process with patients. A link was placed on the services’ website, and we received 35 pieces of feedback, of which 1 piece of feedback spoke positively about how a clinician had supported the patient when an urgent diagnosis was needed.

Staff told us how the practice engaged with partners including the district nursing team, health visitors, secondary care, and social services. Staff explained how they worked alongside partners such as tissue viability services, podiatry, and the lower limb clinic. They also explained how they monitored referrals to those services. Clinical staff we spoke with told us about how they gave safety netting advice to patients about what to do if their symptoms worsened or condition deteriorated. This included when a patient should contact the practice for advice or seek urgent assistance. Staff that managed referrals explained how they monitored referrals to ensure urgent referrals were picked up and appointments were allocated within the timescales. Staff also explained how they audited the clinical system to avoid any referrals being missed. Our review of the system to manage clinical tasks indicated there was a backlog of tasks, however leaders explained they believed there was a technical issue with the system and committed that it would be reviewed.

We asked for feedback about the practice from partners, but they had no specific feedback about this quality statement.

We reviewed how the practice supported patients and their family’s when patients required end of life care. This included discussing patients’ needs at a monthly multi-disciplinary meeting, providing a bypass number to contact the practice directly and supporting people to achieve their preferred place of death. We reviewed the referrals processes and found there were clear processes to differentiate between urgent and non-urgent referrals and to prioritise urgent referrals for suspected diagnosis of cancer. These referrals were continuously monitored and completed on the day of request. The practice audited the system to ensure no urgent referrals were missed. Non-urgent referrals had a target for completion within 1 week. Our review found 1 request for an urgent referral which had been made that day. There were 250 non-urgent referrals, of which some were in progress and the oldest was dated 6 February. We were told staffing levels in the team had impacted on the completion of non-urgent referrals. However, we reviewed the system to manage clinical tasks and found 3,077 tasks in a queue for tasks more than 7 days old which were awaiting allocation. We also found 175 tasks in a queue for tasks more than 30 days old. The oldest task was dated 29 November 2023 and of the 4 tasks we reviewed, 1 included a request for an urgent patient summary from another healthcare provider. The practice was not able to demonstrate that action had been taken to resolve the tasks which meant service users could be at risk of harm. Overall we were not assured the practice had sufficiently embedded systems and processes to manage all clinical tasks or that these were monitored effectively to ensure safe care and treatment.

We spoke with the practice safeguarding lead and they confirmed they were supported by a deputy and the practice also had a safeguarding administrator. The safeguarding lead confirmed they had ongoing engagement with the locality safeguarding lead for advice and guidance about any complex safeguarding concerns. They also had protected time to attend the locality safeguarding meeting and prioritised attendance to ensure the practice was represented and patients were protected. We were told the practice had systems to follow up vulnerable patients that did not attend appointments.

We asked for feedback from partners, but they had no specific feedback about this area.

We found the practice held a monthly safeguarding meeting and were told the agenda was circulated in advance so staff were aware of the patients to be discussed. All clinical staff and system partners were invited to the meeting. We heard system partners attended on agreed frequencies due to their own capacity but always submitted information to the meeting and received the minutes. The practice explained they followed national guidance to code the records of vulnerable patients. We found the levels for mandatory safeguarding training were aligned with national guidance. However, our sampling of 5 staff’s training records found only 2 staff had completed training to the appropriate level for their role. We found 2 members of clinical staff were trained to the incorrect level and a member of non-clinical staff had not completed children’s safeguarding training. We also found the practice held no record of training for 1 member of locum staff. We found evidence a member of staff undertook a clinical session on their own with patients before their disclosure and barring service (DBS) check had been completed. We found another member of staff had their DBS certificate checked to confirm validity but the personnel record did not confirm the certificate was an enhanced level. Overall we were not assured that the practice had effective systems and processes in place to ensure staff were trained to identify vulnerable patients. There was also a risk that ineffective governance processes meant patients were not always safeguarded from the risk of abuse, including the potential for abuse by staff employed by the practice.

According to the results of the recent GP Patient Survey, the practice was below the national average for 3 data indicators. However, the difference was not enough to create a statistical variation in our data. We asked the provider to share details of our Give Feedback on Care process with patients. A link was placed on the services’ website and we received 35 pieces of feedback from patients. One patient’s feedback specifically mentioned how the practice had been very proactive when they needed an urgent diagnosis. The patient also offered their opinion that a specific clinician had been extremely supportive, thorough, and responsive to their needs during their care. The other pieces of feedback did not relate to this quality statement.

We completed interviews with staff and heard clear examples about the information given to patients to advise them about how to identify when symptoms were worsening or their condition was deteriorating. We also discussed the conversations clinicians had with patients that attended the practice for minor surgical procedures. We found patients were told of the benefits of the procedure and the associated risks to help them to decide whether to proceed with the treatment. We also found that staff that managed referrals were clear about the information patients were told when clinicians made referrals. This included what to do if an appointment was not received. Knowing this helped those staff to support patients when they were concerned about the status of their referral.

During the assessment we found evidence of backlogs in the clinical administration inboxes. The practice was not able to demonstrate that action had been taken to resolve these tasks. This meant patients potentially did not have all the information they needed to understand any risks to their health. Our remote clinical searches identified 63 patients with a potential missed diagnosis of diabetes. Our GP specialist advisor reviewed a sample of 5 records, and we found 3 patients had the diagnosis coded in their records but 2 did not. We did not find evidence that 4 patients had been told of the diagnosis and it was unclear whether the remaining patient had been told of their diagnosis. We also found 34 patients with asthma that had been prescribed 12 or more short-acting bronchodilator (SABA) inhalers in a 12 month period. This is an indication of poor asthma control and can be associated with an increased risk of asthma attacks. Of the 5 patients reviewed we found 1 patient had received an appropriate review. Another was overdue an asthma review. We also found 2 patients had been prescribed 12 SABA inhalers in the last 12 months with good asthma control recorded and no mention of overuse of inhalers. The final patient was reviewed in 2020 where it was recorded they had poor asthma control but the patient was not followed up until December 2023. These findings posed the risk that patient existed that did not know of their diagnosis for serious health conditions and did not have information required to manage the risks associated and optimise their health. We shared details of the patients with the practice after the remote clinical searches and they confirmed they reviewed the patient and took appropriate action in response.

Our findings from discussion with all staff groups were that the practice was not able to explain how maintenance schedules were planned and which staff were responsible for oversight and monitoring actions associated with premises risks. Staff we spoke with were not able to confirm responsibility for monitoring of processes such as temperatures of water outlets and fire alarm testing. We found there was a lack of accountability and responsibility for tasks and a lack of oversight of tasks across all 5 sites. Governance had not enabled leaders to identify the ineffective systems and processes. We were not assured there were effective systems or processes that operated consistently or were embedded at any of the sites within the practice.

Our observations found there were a lack of governance systems and processes in relation to the maintenance and management of risks associated with the premises. Examples of our findings included: 3 of the 5 risk assessments for the presence of legionella at the sites had not been appropriately reviewed, nor had the actions been addressed in a timely manner. For example, we found 51 risks had not been actioned from a risk assessment for the Great Hollands site dated 30 November 2021. Some of these were marked high risk. Actions identified in the risk assessments for 2 other sites had also not been addressed. We found risk assessments were booked in the future for the 2 remaining sites. We found there were a lack of processes to consistently monitor the temperature of water outlets to ensure it was safe for use and there was a lack of evidence of flushing water outlets that were rarely used. These findings applied across all 5 sites. We found fire risk assessments existed for all 5 sites, but actions required as a result of the assessment had not been recorded as completed. We also found a lack of process to ensure regular testing of internal fire alarms across all 5 sites. Our observations also found concerns regarding the lack of process to ensure fire alarms were serviced and maintained. We also found general risk assessments for the premises had actions marked as ongoing with no intended date for completion or record the action had been completed. Overall we did not find evidence of effective processes to monitor and manage risks associated with the premises or that the practice had oversight of the risks.

We reviewed the practice’s operational and environmental risk register. We found evidence of environmental risks recorded but did not find evidence of the items identified via our observations. Our findings from our observations and review of evidence meant we were not assured the practice had an embedded set of systems or processes that operated consistently across all the sites which ensured a regular programme of maintenance across all sites. We were also not assured there was an effective process of risk assessment and that when risks were identified, the practice maintain oversight of the risks to manage or reduce them. We were also not assured that risks were responded to effectively or in a timely manner or had appropriate control measures in place to meet and control or reduce the risk.

We asked the provider to share a link to the Give Feedback on Care process on our website. We received 35 pieces of feedback, of which 4 pieces specifically provided positive feedback about clinicians at the practice and the patients’ experiences. We also received a piece of positive feedback from a patient in the information shared by a partner. One piece of negative feedback explained a patient had found reception to be unhelpful but did not reference their ability to support the patient to support them to receive safe care. We reviewed the results of the GP Patient Survey, in particular the percentage of respondents surveyed who stated that during their last GP appointment they had confidence and trust in the healthcare professional they saw or spoke to. Although the practice’s result was below the national average, there was no statistical variation.

Staff we spoke with told us they found the practice to be very supportive of their training and development. Staff working in advanced clinical roles explained there were clear processes to identify who they could seek support and guidance from during the clinical session. We found these explanations were consistent with the practice’s clinical supervision policy. Staff we spoke with also told us about the monthly educational training session where they could receive updates. Staff working in the clinical multi-disciplinary team all spoke of the weekly meeting where they could receive information, raise concerns, or seek advice and guidance. We also saw evidence of a skills and competence matrix to ensure staff did not undertake clinical activities beyond their competence. Staff we spoke with told us of this document and that it was used effectively. After our assessment identified the concern regarding validity of professional registrations, the practice immediately carried out checks to ensure registrations were valid for the staff sampled. Our interviews with staff confirmed they understood the practice process for obtaining DBS certificates for staff. However, our observations found this process had not been followed.

We found evidence the practice used a skills matrix to confirm the tasks and roles that staff were suitable to carry out. We saw evidence of a policy to confirm the supervision arrangements for clinical staff working in advanced roles. We were provided evidence the practice audited the prescribing of non-medical prescribers on a regular basis. Where opportunities to improve existed, feedback was provided. The recruitment policy confirmed the process for obtaining disclosure and barring service (DBS) certificates for staff. Our sampling of 4 staff personnel records found concerns such as a member of staff undertook a clinical session without a valid DBS check. Checks to ensure certificates remained valid did not confirm the certificate was for the correct level for the role. 2 members of staff had been employed with historic DBS certificates and the decision not to obtain new certificates had not been risk assessed. We were provided evidence of a staff development and training policy which included a mandatory training list. However, we found the practice did not have an effective system to monitor and manage staff training compliance to ensure staff were up to date with their knowledge and skills. We sampled staff training and found for 2 locum staff the practice either had incomplete or no records of training. We also found examples of staff employed by the practice that either had not completed training or were trained to the incorrect level for their role. This finding included infection prevention and control training which had an impact on patient safety. The practice’s system to monitor training had not identified that a newly appointed member of staff had not completed training courses required by the practice within 3 months of starting, as per the practice induction policy. Recruitment and training processes did not ensure that all staff were suitably experienced, competent, and able to carry out their roles.

We asked the provider to share details of our Give Feedback on Care process on their website and although we received 35 pieces of feedback, none were specific to this area.

In response to our concerns about recording staff’s immunisations status, the practice explained they were in the process of determining the status of all the staff’s immunisation history to determine which staff required further vaccinations and which staff may need support from the occupational health team. The practice told us they were aware they did not have complete records for all staff and had been requesting records since the merger and a GP partner had oversight. However, our findings were that this issue did not apply only to merged staff, it applied to existing staff as well. We heard that the practice infection prevention and control (IPC) lead had not yet completed their specialist training, but they confirmed this was booked for the future and in the interim period support was available from the Integrated Care Board (ICB) lead. After the assessment, the provider sent additional evidence which showed this member of staff had completed IPC training to a different level than we observed in their training record. The provider also provided evidence which confirmed they had now completed specialist IPC training.

During our onsite visits we conducted observations of the premises. We found the following concerns: We reviewed 7 personnel files and found 2 contained no records of immunisations. We found records of immunisations were incomplete for the 5 other personnel files we reviewed. This placed service users at risk of receiving unsafe care and treatment. We carried out observations in clinical rooms and found 2 rooms did not contain any couch roll. We also found multiple examples of consumable items where the expiration date had passed. Our observations also found 2 clinical rooms where sharps boxes were not assembled or were not stored securely. At the Crowthorne site we found bins were not stored securely outside. These included bins used to store clinical waste awaiting collection. The findings from our observations meant we were not assured there were effective systems or processes to protect patients from the risk of infection. After the site visit the provider sent additional information to explain the rooms we observed were not in use on the day of the visit and their processes were to prepare rooms at the start of each day. However, this explanation was not provided at the time of the visit.

We found there was a lack of effective process to ensure staff immunisations were recorded at the point of recruitment. We found there was a lack of oversight of this process because we found staff that did not have compete or only partial records of vaccinations recorded. During the assessment we were provided evidence of a template to record the status of staff’s vaccinations which had been developed by the practice. The immunisations required followed national guidance. Risk assessments were required where evidence of vaccination could not be provided. However, due to the findings in our observations regarding the missing or partial immunisation records, we were not assured this was an embedded system. We were provided with the practice’s infection control policy. We found this was not up to date because it still detailed the previous infection prevention and control (IPC) lead despite a new IPC lead being in role. We found IPC audits had been carried out regularly across all 5 sites and improvements were made over time. Overall we were not assured there were effective or embedded governance systems and processes to ensure patients were protected from the risk of infection when receiving care and treatment from the practice.

We asked the provider to share details of our Give Feedback on Care process with patients. A link was placed on the services’ website and we received 35 pieces of feedback from patients. Of these, 3 pieces of feedback related to prescriptions and reported that the process to obtain a repeat prescription was difficult and they were not issued in a timely manner. We also reviewed the feedback we had received from patients dating back to July 2023. We found 2 examples of patients reporting they had experienced delays to receive repeat prescriptions. One patient reported a 10 day wait and another stated they experienced a 12 day wait. One of the patients reported when the patient asked why it took so long to process the request they had been told it was due to the number of patients registered at the practice. Although specific to a single area of this quality statement, the feedback indicated there was a possible theme that patients had experienced when accessing care and treatment from the practice.

We heard in interviews that the practice was aware some patients were overdue routine monitoring tests. Several reasons were given as causes including a merger with another practice in July 2023. The practice reported they had found a lot of those patients were overdue routine monitoring and reviews and the practice was now working to reduce the number of patients. Secondly, the practice reported they had a shortage of phlebotomists, which combined with staff sickness through the winter period had meant a lot of blood tests had been booked but had to be cancelled. We identified 4 patients were prescribed a combination of clopidogrel and omeprazole contrary to a medicines safety alert issued by the Medicines and Healthcare products Regulatory Agency (MHRA), the practice explained it was aware of this finding prior to the assessment. It was explained some patients had already been contacted and informed of the risk but had not had their medicines changed yet. We reviewed an audit completed by the practice which focused on prescribing of an antibiotic, amoxicillin. The Integrated Care Board compliance target rate was 80% and the audit found the practice performance was significantly below the target because it was 30%. However, we found the practice was aware and had identified the cause and was working to improve compliance. The audit was due to be repeated in March 2024 and the staff interviewed told us from their own observations they were confident that improvement would be achieved. Our discussions with staff regarding the management of blank prescription stationary did not assure us there was an effective process or that staff understood the requirements of how to keep this stock secure.

We reviewed the records used to log stock and found these records to be incomplete and 4 boxes of blank prescription stationary could not be accounted for. This meant there was a lack of effective system or process within the practice to track and monitor the distribution of stock across the practices’ sites. We sampled 4 Patient Group Directions (PGDs) and found all of these had been incorrectly authorised. PGDs are used to authorise staff that are not qualified prescribers to administer medications to patients. The PGD should be signed by the clinician requesting authorisation before the authorising prescriber, our sampling found this had not happened. Our sampling of emergency medicine and equipment found checks of stock levels and expiration dates were not taking place on a consistent basis and were not following the practice’s own policy. For example at the Birch Hill site the log stated the check should be weekly and we found checks were not following that schedule. We also found checks were not taking place routinely at the Owlsmoor site. Our findings were that there was no inventory with the emergency medicines and checks had taken place in August 2023 and January 2024 but there was no record of a checklist. We also found 3 medicines recommended in national guidance were not stocked and there was no risk assessment to support the decision. This finding applied to 3 sites. We found significant gaps in the monitoring of temperatures of fridges containing medicines prior to January and February 2024. This applied to all the sites. However, we found evidence of a revised process that was recently implemented and had driven improvement in the process.

The practice had a process to manage medicines safety alerts from the Medicines and Healthcare products Regulatory Agency (MHRA). Alerts were received into a general inbox and we were told this inbox was monitored at least 2 times per day. Alerts were distributed to staff for awareness and responsibility for actioning the alert belonged to the most relevant clinician. We also saw documentary evidence that alerts and updates were discussed in the weekly multi-disciplinary team meeting. However, our findings in outcomes were that this process was not operating effectively or consistently. The findings of our observations and conversations with staff meant we were not assured that the practice had an effective or embedded process to monitor the stock and expiration dates of emergency medicines and equipment. We checked the process in operation and found checks had taken place on an inconsistent frequency across the sites and there was a lack of formal process to be followed. We found there was a lack of system and process to securely track and manage the stock of blank prescription stationary because records used to track and record stock were incomplete. We found the process to authorise Patient Group Directions (PGDs) did not correctly authorise staff to use the PGD when administering medications. Overall, we were not assured the practice had effective governance of medicines management process and, there was a lack of oversight and quality assurance because the practices’ own governance had not identified these findings.

We reviewed national data for the practice’s performance regarding prescribing of antibiotics and found significant positive variation for 1 of the indicators and no variation for another. A GP specialist advisor (SpA) carried out remote searches of the practice’s clinical system and the searches found: 59 patients prescribed an aldosterone antagonist plus an ACE/ARB were potentially overdue monitoring according to the search results. ACE/ARB medicines are used to treat raised blood pressure, heart failure and chronic kidney disease. This combination is contrary to a historic medicines safety alert issued by the MHRA and where prescribed, patients require close monitoring due to the risks associated. The GP SpA reviewed 5 patients records, and all were overdue monitoring. However, we saw evidence the practice had sent recall reminders in the last 2 months. Our review of patients taking a disease modifying anti-rheumatic drug (DMARD) found 6 patients potentially overdue monitoring. Our GP SpA reviewed 5 records and found all had up to date blood tests but all were overdue blood pressure monitoring. We found evidence 4 of the 5 patients had recently been reminded to book monitoring tests. Our remote clinical searches also included a review of patients prescribed medicines that require monitoring. Our GP SpA reviewed a medicine used to treat irregular heart rhythm, 21 patients were identified by the search of which 13 were indicated to potentially be overdue monitoring. We reviewed 5 patients and found all 5 were overdue blood tests. Our GP SpA saw evidence 3 patients had been recalled for monitoring tests but had not yet attended. We also only found evidence that the prescriber had checked monitoring was up to date before prescribing for 1 of the 5 patients. After the remote clinical searches the practice confirmed it would review all the patients identified and take appropriate action in response to the findings.