Another Swindon GP practice has been told it needs to improve after a recent inspection by the health watchdog.

There was a risk Ridgeway View Family Practice potentially missed diagnosing patients with conditions including diabetes, according to the Care Quality Commission report published this week.

Inspectors also found the Wroughton practice did not consistently monitor patients' health when they were prescribed high-risk medicines.

Ridgeway View was rated 'requires improvement' in three key categories: whether the service was safe, effective and well-led. This is a downgrade from its 'good' record in 2018.

The GP practice says it is addressing the improvements as a "matter of urgency" and that many changes have already been implemented since the inspection in July.

While Ridgeway View kept people safe and safeguarded from abuse, most of the problems highlighted by inspectors stemmed from the lack of "consistent" monitoring and auditing.

The report says: "There were no clear systems for overview of the quality of service provided. This included recruitment, health and safety, infection prevention, monitoring of non-medical prescribers and medicine reviews."

For example, of the 17 patients prescribed a high-risk immunosuppressant drug, five had not been regularly monitored.

One patient was prescribed Azathioprine and another drug which had a different name but was the same medicine; this duplication put the patient at risk.

Inspectors wrote: "We reviewed the use of some high-risk medicines and looked at how patients were being monitored to ensure safe prescribing.

"We saw a lack of consistent monitoring and we saw from the electronic patient records system used, that some searches had never been run.

"This meant the practice had not reviewed patients prescribed some high-risk medicines."

In some cases, health alerts had not been "actioned" which inspectors concluded could put patients "at risk". 

37 women were prescribed anticonvulsant medicine Pregabalin without being reviewed. They could have been at risk because the drug should not be given to women during pregnancy or those planning a pregnancy.

At the time of inspection, the practice was prescribing nine patients with two medicines despite guidance from the MHRA to suggest Omeprazole could reduce the effectiveness of Clopidogrel. 

"The practice responded during the inspection and three patients identified as at risk had been contacted and the remaining six were in the process of being contacted," the report adds.

Inspectors also found that there were seven patients with a potential missed diagnosis of diabetes.

The Barrett Way surgery did not follow up on patients presenting with symptoms in a "timely and appropriate way".

"Some of the issues related to how tasks were managed by the clinical staff.

"If tasks for actions were not correctly and consistently managed, the risk then was that patients would not be clearly identified for monitoring and treatment," the CQC report concludes.

The practice was told that its risk registers needed to be "further developed" because, when they visited, assessments were not being used to reduce "all identified risks".

At the time of the July visit, staff levels were not high enough to meet demand and staff were working extra hours but the practice reassured inspectors that recruitment was ongoing.

These staffing concerns did not seem to impact care because patients were able to access effective treatment.

A Ridgeway View Family Practice spokesman said: “The safety and wellbeing of our patients is always our number one priority, and we are pleased that the Care Quality Commission noted in its report that our teams worked together to ensure people had access to effective care and treatment. 

“This underpins everything we do at Ridgeway View, and is something inspectors saw first-hand during their time with us, with this latest report highlighting how our staff work to help patients live healthier lives. 

“Of course, we know some improvements are required, and these are already being addressed as a matter of urgency, with many changes having already been implemented since the time of our inspection more than two months ago. 

“Ridgeway View takes the findings of the CQC extremely seriously, and we would like to reassure patients that we are doing all we can to overturn our rating, and remain hopeful that any future visit will take account of the positive work that has already happened, as well as that which will continue over the coming months.”