We had previously carried out an announced comprehensive inspection at Saffron Health on 23 and 25 October and 6 November 2018. The overall rating for the practice was requires improvement. The full comprehensive report on that inspection can be found by selecting the ‘all reports’ link for Saffron Health on our website at .

At that inspection we identified breaches of Regulation 12 (Safe care and treatment) of the Health and Social Care Act, and issued the practice with a Warning Notice. This inspection was an announced focused inspection, carried out on 20 March 2019, to confirm that the practice now met the legal requirements in relation to the breaches in regulations. This report covers our findings in relation to those requirements only.

Our key findings from the areas we inspected for this focussed inspection on 20 March 2019 were as follows:

• Since the inspection in October and November 2018 the practice had taken significant steps ensure patients health was monitored in a timely manner to ensure medicines were being used safely and followed up on appropriately.
• The monitoring systems in place to ensure patients in receipt of high risk medicines were effective and kept patients safe from harm.
• There was an effective system to review the medicines on repeat prescriptions to patients.
• There was an effective system to ensure that patients safety alerts received from the Medicines & Healthcare products Regulatory Agency and other sources were dealt with in manner that protected patients.
• The practice had an effective process to safeguard patients at risk of abuse.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

This practice is rated as Requires Improvement overall.

The key questions at this inspection are rated as:

Are services safe? – Inadequate

Are services effective? – Requires Improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires Improvement

We carried out an announced comprehensive inspection at 612 Saffron Lane on 23rd October 2018 and at 509 Saffron Lane on 25th October 2018. We carried out a follow up visit on the 6th November 2018 to obtain further information on clinical areas which were identified at the visit on 25th October. The comprehensive inspection was completed due to the practice being newly registered in October 2017.

At this inspection we found:

• The practice had systems to record and investigate significant events and complaints. When incidents did happen, the practice usually learned from them and implemented some systems to improve their processes.
• The practice did not have effective systems for receiving and actioning nationally available medicine and patient safety alerts.
• The practice did not have effective processes to ensure testing was being done for patients who were prescribed medicines requiring regular monitoring. We also found the practice did not have effective systems to assure that patients were being prescribed medicines safely.
• The practice had a mix of clinical staff providing appointments suitable for a range of patients. This included a pharmacist, a paramedic and nurses and doctors trained in specific areas. The practice also had specialised administrative roles for liaising with patients and dealing with prescription requests.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
• The practice were involved in research projects in the East Midlands network and had achieved the status of a leadership practice for training.

The areas where the provider must make improvements are:

• Ensure care and treatment is provided in a safe way to patients

We also identified an area of practice where the provider should make improvements:

• Review the process for monitoring and acting on patient satisfaction and feedback

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.