Great Barr 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.

At our last assessment, we rated this key question as Inadequate. At this assessment, the rating has changed to Requires Improvement

At our last assessment, the service was in breach of legal regulation in relation to:

• The provider was unable to provide evidence that actions from risk assessments had been completed to ensure the health, safety and welfare of people. This included infection control audit.
• The provider was unable to demonstrate they complied with the relevant safety alerts issued by the Medicines and Healthcare products Regulatory Agency (MHRA).
• The provider was unable to demonstrate that incidents and significant events was thoroughly investigated and learning was shared with the wider team to mitigate future risks.

At this assessment, the service was in breach of legal regulation in relation to:

• The provider had no process in place to ensure that staff providing care and treatment to patients had the skills and experience to do so safely.
• The provider was not complying with the relevant Patient Safety Alerts ensuring the appropriate actions had been taken.
• People on high risk medicines and with long term conditions were not being monitored appropriately.

Systems were in place to protect individuals from abuse and avoidable harm; however, we found safeguarding procedures needed improvement to ensure those at risk were regularly reviewed and their safety was clearly prioritised across the service.

Health and safety procedures were in place, and the premises were appropriately maintained. We found improvements had been made in the management of medicines, however systems needed further strengthening to ensure regular reviews were in place and people were monitored appropriately.

We found safety incidents were investigated, and the process for sharing learning had been strengthened to identify shortfalls and prevent recurrence and regular practice meetings were now in place where learning was shared with the practice team to mitigate any future risks.

Since the last assessment in November 2024, the leadership team had reviewed the competencies of staff to ensure the appropriate qualifications had been completed prior to commencing roles within the practice. However, we continued to identify concerns in the clinical supervision of some staff.

Pre-employment checks were completed, and staff received safeguarding training relevant to their roles, alongside regular appraisals and ongoing training in other areas to maintain high standards.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Since the last assessment in November 2024, a new leadership team had joined to strengthen the overall management of the practice. We found systems had been reviewed and new processes had been implemented to ensure the service 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 provider 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 issues that had been identified in the practice. Staff felt there was an open culture, and that safety was a top priority. The provider 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. New processes had been introduced to ensure lessons were learnt from individual complaints and shared with the practice team to improve the quality of care. We reviewed a random sample of complaints and found the provider had responded in a timely manner and had offered apologies to people.

Information reviewed demonstrated that people had opportunities to provide feedback and they knew how to make a complaint. Feedback and information were available in the practice and on their website. The practice had a complaints champion in place to support people who wanted to make a complaint.

The service 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.

Leaders told us that clinicians made appropriate and timely referrals in line with protocols and up to date evidence-based guidance. Processes for the management of test results had been strengthened and shared with the clinical team.

The provider was part of a primary care network and they attended regular meetings. We also found there were a range of structured meetings now in place. These included clinical meetings, safeguarding and practice team meetings. Information was regularly shared with all the practice team to promote learning and quality improvements.

Effective systems had been implemented for processing information relating to new people including the summarising of new records. We found clinicians made appropriate and timely referrals in line with protocols and up to date evidence-based guidance. This was supported by a system in place to ensure all patient information including documents, laboratory test results and referrals were reviewed and actioned in a timely manner.

We found systems needed strengthening to ensure there were effective processes in place to maintain safeguarding registers. The processes in place were not regularly updated and we identified gaps in the information held on people with potential safeguarding concerns. We reviewed a random sample of clinical records and found that some had been appropriately coded where safeguarding concerns had been identified, however some patients’ records had not been updated.

There were processes in place to follow up children and young people who were not brought to their appointments with the provider and for secondary care appointments and safeguarding meetings were held on a regular basis to review people at risk. Community teams were invited, however the practice told us they struggled to get people to attend, however they ensured information was shared appropriately for the care of people with safeguarding and vulnerable concerns.

Following the onsite assessment, we received an action plan from the leadership team which provided assurances that a complete review of the current safeguarding procedures was going to be implemented.

There was a safeguarding lead for children and adults and all staff were aware of who to speak to if they identified a safeguarding concern. The service 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 service shared concerns quickly and appropriately.

There was a policy in place for the renewal of DBS checks. Records we examined showed that all staff had a DBS check in place. DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable.

The service 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.

Staff could recognise a deteriorating patient and knew of action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

Leaders told us that they worked with services locally to understand and manage risks. The practice also had registers in place to support those patients who were vulnerable or who had mobility or communication needs.

All staff were trained in basic life support and receptionists were aware of actions to take if they encountered a deteriorating or acutely unwell patient and had been given guidance on identifying such patients.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

From the evidence provided by the leadership team we found that health and safety, security and maintenance of the building was regularly reviewed to ensure this was to a safe standard.

Health and safety related assessments and procedures to manage health and safety were in place. This included fire safety. We found risk assessments had been completed in September 2024 and actions identified had been acted on. For example, the fire risk assessment had identified chairs in the waiting area were a potential fire risk due to being damaged. Action had been taken and the chairs had been replaced. Staff had been provided with training in health and safety related topics such as fire safety, infection control, basic life support and resuscitation training. Staff reported during discussions that they had no concerns regarding the arrangements in place to ensure health and safety.

There were policies and procedures in place for the management of health and safety. Fire safety policies were in place and staff were aware of how to access these. Fire marshals had undertaken additional training for the role. Systems were in place for the regular checks of fire alarms, extinguishers and fire evacuation procedures.

The practice had completed assessments in place for the control of hazardous substances. Evidence provided by the practice showed equipment was regularly calibrated and electrical items were PAT (portable appliance testing) tested.

There was a business continuity plan in place which was monitored and reviewed. Reception and administration staff who handled calls to the practice and arranged appointments with the clinical team were aware of potential red flag symptoms. Staff knew when to notify a GP or other clinicians with concerns about a patient who may be acutely unwell and/or deteriorating.

During our site visit we found the premises were well maintained. The premises were clean and contained the appropriate facilities to support infection prevention and control. The provider detected and controlled potential risks in the environment. They made sure equipment, facilities and technology supported the delivery of safe care. Regular checks were carried out on the premises, facilities and the equipment provided. Contracts were in place to ensure the premises were clean and well maintained. Clear signage around the building supported people and staff in the event of an emergency evacuation.

At the last assessment in November 2024, we found the practice had not ensured that staff working in clinical areas had received the appropriate training and monitoring to confirm they were competent in their role. At this assessment, we found systems had been implemented to ensure staff working in clinical roles were supervised, but they were not effective to ensure all staff had the relevant qualifications to carry out their role appropriately. For example, we found one of the nursing team was carrying out reviews of patients with asthma but had not completed formal training in this clinical area. We were told training had been provided inhouse, however we were unable to gain assurances that the appropriate supervision was in place and staff were aware of clinical guidelines in relation to prescribing and appropriate timescales for follow up. During the remote clinical searches, we found patients had been prescribed steroids but had not been provided with a follow up appointment in line with recommended guidelines. Further clinical reviews showed non-clinical staff carrying out diabetic reviews without the appropriate supervision or qualifications to complete these types of clinical assessments.

The practice had recruitment policies in place and all staff had completed disclosure and barring checks. All newly employed staff had completed an induction to ensure they were competent in carrying out their role. We reviewed 2 personnel files and found appropriate checks such as previous employment record and proof of identity checks had been completed. Personnel folders were well organised and there was a systematic approach to ensure that personnel folders were managed appropriately. We found staff immunisation status records were in place.

The practice had recently formed a new partnership which included a new leadership team. The leadership team were planning to undertake a full review of staff roles and responsibilities to identify key operational areas and drive improvement by developing staff. A role mapping exercise was due to take place to identify gaps in the workforce and potential areas for development.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The practice had policies in place for infection, prevention and control which was accessible to staff and staff were aware of the action to take. For example, in the event of a sharps or contamination injury.

The practice had a designated infection, prevention and control lead and all staff had completed infection prevention and control training relevant to their role and on speaking with staff they were aware of the systems and processes to follow to ensure clinical specimens were handled safely.

At the last assessment in November 2024, we were told that an infection control audit had been completed, however the leadership team were unaware of the outstanding actions the audit had identified. At this assessment we found an infection control audit had been completed in March 2025. The practice had achieved 97%. The actions identified had been completed. For example, clinical waste bags were to be labelled appropriately with the practice details. We saw evidence to demonstrate this was now in place. The processes had been strengthened to ensure that curtains used in consultation rooms were changed in line with recommended guidelines.

Cleaning schedules were in place and followed. We observed the general environment to be clean and tidy and cleaning rotas were in place. Sharps bins were available in all clinical rooms which were signed, dated, safely sited and were not over-filled.

The leadership team had reviewed their systems and processes since the last assessment in November 2024 to support the safe prescribing of medicines. The practice had a clinical pharmacist and also worked with the clinical pharmacists from the local Primary Care Network (PCN) to monitor people and the prescribing of medicines. We found some improvements in medicine monitoring, however there were some areas that required further strengthening. For example, as part of the assessment, we carried out remote clinical searches. We reviewed the number of people with frailty or aged 75 years and over who had been prescribed medicines to reduce the risk of blood clots called direct oral anticoagulants (DOACs), who had not received the appropriate monitoring in the past 6 months. NICE guidance recommends that monitoring should be done at least every 4 months. The search identified 17 patients on these medicines who had potentially not received the appropriate reviews. We reviewed a random sample of 5 clinical records and found the people overdue blood monitoring had been identified by the practice and requests had recently been sent for blood tests to be completed. A further review showed 1 person had not had their weight checked in the past year. Accurate weight is required to calculate creatinine clearance levels when people have blood tests completed. 4 patients had not had the required monitoring done in the past 7 to 10 months, this demonstrated people were overdue monitoring in line with recommended guidelines. A second search identified patients on medicines called gabapentinoids which are used to treat epilepsy or nerve pain who had not been reviewed in the past 12 months. We reviewed a random sample of 5 records and found all 5 patients were overdue monitoring with 2 people not having had a medicine review since 2023. The clinical pharmacist was aware of the outstanding reviews for this group of patients and at the time of the assessment was reviewing the patient list.

At the last assessment, the provider was unable to demonstrate they had processes in place to ensure the systems to contact people about potential risks identified through safety alerts were effective. At this assessment we found some improvements had been made to inform people about risks, but further strengthening was required to ensure all patients were aware of potential risks and were provided with the appropriate reviews and care. For example, we carried out a clinical search to identify women of child bearing age prescribed teratogenic medicines, that have the potential to increase the risk of birth defects. We reviewed a random sample of 5 clinical records and found some patients had been informed of the risks, usually by text message, however most people were not on effective contraception as recommended by clinical guidelines so patients could still be at risk without the appropriate contraception in place.

Emergency medicines, vaccines and medical equipment had clear monitoring processes in place. There were appropriate arrangements in place for the management of vaccines and for maintaining the cold chain and a data logger was in place. We saw fridge temperatures were routinely monitored and vaccines reviewed at random were in date and stored appropriately. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments.

Staff told us they involved people in reviews of their medicines and helped them understand how to manage their medicines safely. We carried out a clinical search to identify the number of people who had received a medication review in the past 3 months. The search identified 456 people. We reviewed a random sample of 5 clinical records and found effective reviews had been completed by both the GPs and pharmacists.

Staff managed prescription stationery appropriately and securely. 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 issued by the provider was in line with local and national averages. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.