Marine Lake Medical Practice in West Kirby has been found in breach of regulations and downgraded after an inspection found issues with the safe management of medicines.
The Care Quality Commission (CQC) visited the practice, at the Concourse, in November and discovered:
- There was no system in place to ensure all alerts and information relevant to general practice were received, disseminated, monitored and acted upon
- Medication reviews were not always completed and reviewed regularly for patients living with long term conditions
An inspection of case records revealed that:
- 4 out of 37 patients prescribed a medicine used to treat mood disorders did not have recent blood monitoring results documented on their records, and repeat medicine prescriptions were issued without checking their status
- 233 out of 2,071 patients prescribed certain medications used to treat high blood pressure had not attended for the required monitoring in the last 18 months
- 6 out of 70 patients prescribed warfarin had not had been monitored correctly
They also found issues with the monitoring of patients prescribed disease modifying anti-rheumatic drugs, antiarrhythmic medications and those who were on a medicine used to treat heart conditions.
In addition, the CQC identified that the system for coding patients with potential health conditions such as chronic kidney disease and diabetes needed improvement so that patients had access to the health checks they required.
They also raised concerns regarding the overnight storage of blank prescription forms, and found there was no formal documented review of the work of non-medical staff prescribing medication, although they were supervised.
The report states: “The provider was not able to demonstrate that it remained safe to prescribe medicines to patients where specific, frequent, monitoring was required.
“Patients were having blood tests arranged via the hospital, but the provider was not routinely recording that these indicated it was safe to continue prescribing the medicines.
“This was rectified during the inspection and a system put in place to document test results fully.”
The report adds that the practice had told them it had begun to resolve the issues identified: “The provider gave us a plan of action at the time of inspection to address the concerns found by the searches which addressed actions needed. They had put systems and processes in place to help ensure patients requiring careful monitoring due to their prescribed medicines were monitored as required. We will follow up these actions at the next inspection of the practice.”
Marine Lake Medical Practice said it was “disappointed” at being downgraded from ‘good’ to ‘requires improvement’ and is “very confident” it will be upgraded when it is reinspected.
In a statement, business manager Charlie Taylor-Jones told West Kirby Today: “After a very challenging three years for the NHS, which involved COVID, a national blood bottle shortage and a cost-of-living crisis driving a recruitment crisis in the NHS, we are extremely disappointed by the CQC rating despite all the hard work our staff do, to care for our patients.
“We welcome all feedback, as we know we can always learn from it and improve what we do. We are submitting an action plan to the CQC in January and will be asking them to re-inspect us in March, before we move into our new building. We are very confident we will regain our rating of good in these areas. We are pleased that our hard work, during unprecedented times for Primary Care, has been recognised in the feedback and that the ratings in three out of five areas, Responsive, Well Led and Caring were awarded as good.
“We are fully engaged with the CQC and pleased that the changes already made during the inspection process were acknowledged by the CQC. We understand that this result may worry some of our patients, however we would like to re-assure our patients we are working extremely hard in the areas highlighted to ensure our services are Safe & Effective in all aspects and to regain our good status.”
The inspection also found that:
- There were sufficient staff who were suitably qualified and trained
- Patients were treated with respect and were involved in decisions about their care
- The practice understood its patient population and adjusted how it delivered services to meet the needs of its patients
- Patients could access care and treatment in a timely way
- The practice was led and managed effectively, leaders were accessible and supportive
- There was an effective governance framework in place in order to gain feedback and to assess, monitor and improve the quality of the services provided
The CQC report can be found at https://www.cqc.org.uk/location/1-958905318