Carnarvon Medical Centre rated inadequate by Care Quality Commission

The Carnarvon Medical Centre, in North Road, Westcliff, was criticised by the Care Quality Commission and placed into special measures following an inspection.

In three sections – safety, effectiveness and well-led, the centre was rated inadequate while it was described as good for caring for patients.

Vaccines were “not appropriately stored, in line with PHE guidance to ensure they remained safe and effective”.

The practice was told to improve the monitoring of fridge temperatures used to store vaccines, but this was not in relation to Covid-19 vaccines.

The report, published on January 22, also claimed leaders could not fully demonstrate they had the capacity and skills to deliver high quality, sustainable care. Other points in the report included:

• The practice did not learn and make improvements when things went wrong nor did it have appropriate systems in place for safe management of medicines.
• Where reviews of high-risk medicines had been undertaken, they were not recorded consistently in the patient’s record.
• There was no evidence of patient care plans on the system and although inspectors saw posters on display describing the signs and symptoms of sepsis, clinical staff and reception or admin staff could not clearly describe this.
• The practice did not have effective processes for managing risks, issues and performance, according to the commission.
• Some anti-bacterial prescribing remained high and required improvement, while childhood immunisation uptake and cancer performance indicators continued to be below the national minimum targets.

A spokesman for the centre said: “We sent a robust action plan to the commission on January 18 regarding any issues and are working on it currently, having completed some of the actions.”

Bosses say the mishap over vaccines happened because a nurse was on annual leave and the error was not picked up by admin staff trained to check the fridges.

But the team insist their other practice nurse checked the fridge temperatures every day she was in the clinic to ensure temperatures were not out of range. Fridges are also “continuously monitored by nurses”.

The spokesman added: “Just before Christmas one of our fridges malfunctioned and we were able to trace the time it happened and the temperature it recorded straight away. We contacted Public Health England and decided that while they could be used ‘off licence’, we were not happy to do this. While we don’t like to waste resources we feel this was the right decision for the safety of our patients.

“All admin staff will be given training on how to check the fridges and we will implement a procedure that admin staff will always check temperatures before start of surgery every morning.”

The visit was carried out on November 19 2020.