The Mayfair Medical Centre

On this page

• 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 looked for evidence that people were protected from abuse and avoidable harm. We assessed all the quality statements from this key question. At our last inspection, we rated this key question as requires improvement. At this inspection, the rating has changed to good. Leaders had made noticeable improvements that included appropriate Disclosure and Barring Service (DBS) checks, management of legionella, emergency lighting, monitoring of high risk medicines and blank prescriptions.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. Representatives from the Patient Participation Group (PPG) felt the leaders took concerns seriously and proactively made improvements to the service. Managers encouraged staff to raise concerns when things went wrong. During staff meetings, the whole team discussed and learnt from clinical issues. Staff felt there was an open culture, and that safety was a top priority. The practice had processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Learning from incidents and complaints resulted in changes that improved care for others.

The practice worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. There were systems in place for processing information relating to new patients. The practice worked with other providers to deliver shared care and when patients moved between services, particularly for patients with learning disabilities or complex needs. Referrals and test results were managed in a timely way. The leaders explained they had oversight of the workflow tasks to ensure they were all responded to promptly. On the day of the inspection, we did not find any delays in the patient workflow tasks. There were processes in place to act on correspondence received by the practice with a designated member of the team having oversight.

The practice worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect. The practice shared concerns quickly and appropriately.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. The practice told us that they monitored staff training closely and that staff received reminders to remain up to date with their training. We reviewed safeguarding children and vulnerable adults policies and found these to be up to date. Staff knew who the safeguarding lead was and how to report any concerns. The practice had a system to highlight vulnerable adults and children on their medical records, maintained a list of vulnerable people and acted on concerns working in partnership with other organisations including the Primary Care Network (PCN). There were monthly meetings between the practice and other health and social care professionals, such as health visitors and district nurses, to support and protect adults and children at risk of significant harm

The practice worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Emergency equipment and medicines was maintained and regularly checked to ensure that it was in date. All staff had completed sepsis awareness training, basic life support, and anaphylaxis training relevant to their role. Staff could recognise a deteriorating patient and knew of action to take. This included immediate advice to give people and how to escalate risk to an appropriate clinician. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

The practice detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. There was a business continuity plan in place which was monitored and reviewed regularly.

Contracts were in place to ensure the premises were maintained. Health and safety risk assessments and audits had been undertaken and risks identified had been addressed. We observed fire exits were clear and fire safety equipment was easily available and regularly checked.Staff were aware of what to do in an emergency and where emergency medicines and equipment were stored. Allocated staff also knew how to safely manage spillages of bodily fluids. We observed that the clinical rooms and offices used by the GP practice were fit for use and there were daily room checks on opening and closing. All equipment had been checked and calibrated as required.

The leaders made sure there were enough qualified, skilled and experienced staff, who received support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

There were a range of clinical and non-clinical roles within the practice. We found training was up to date, learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence. Safe recruitment practices were followed. We checked five staff files, and found staff had completed role-specific training and appraisals were detailed and signed accordingly. All staff files we checked had up-to-date mandatory training that was at the appropriate level. Staff responsible for specific clinical interventions, for example, reviews of people with learning disabilities, long-term conditions, cervical screening, and childhood immunisation, told us they received specific training and the practice showed us this on the site visit.

The practice assessed and managed the risk of infection. The leaders ensured that facilities and equipment were safe, and that equipment was maintained according to manufacturers’ instructions. Risk assessments and audits were completed, and actions were taken to mitigate risks. Leaders told us 9 new boilers were installed this year as per the practice’s safe water policy. The practice had a designated infection, prevention and control lead and all staff had relevant training. Cleaning schedules were in place and followed. The premises was visually clean, hygienic, and uncluttered. Patients told us the practice was always clean and well-maintained.

The practice made sure that medicines and treatments were safe and met people’s needs, capacities, and preferences. They involved people in planning, including when changes happened.

Staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely. People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms. Staff received regular training, were competency assessed on medicines optimisation, and felt confident managing the storage, administration and recording of medicines. Staff managed prescription stationery appropriately and securely. Staff followed protocols to ensure they prescribed all medicines safely, and ensured people received all recommended medicines reviews and monitoring.

Medicines including controlled drugs were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments. The practice had effective systems to manage and respond to safety alerts and medicine recalls. Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring. Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. Prescribing data reviewed as part of our assessment confirmed this. For example, the number of antimicrobials, gabapentinoids and hypnotics issued by the practice were lower than national averages. There were regular clinical audits of prescribing that focused on improving care and treatment.