Romsey Medical Practice

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 people were protected from abuse and avoidable harm.

This is the first inspection for this service since its registration with CQC. This key question has been rated as Good.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

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. Constructive feedback from patients was used to make positive changes in the service. For instance, when patients expressed concerns about consultations feeling rushed or limited by time, staff responded by reassuring them that appointments would allow sufficient time for each individual, ensuring that no one would feel hurried during their consultation.

Feedback on waiting room comfort and appointment scheduling also contributed ideas for improving the service environment and appointment planning. These actions were documented, reviewed within governance meetings and evidenced reflective continuous service improvement during staff meetings. Staff felt there was an open culture, and safety was a top priority. The service 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 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. There were systems in place for processing information relating to new people. The service worked with other services to deliver shared care and when people moved between services, such as informing the person’s NHS GP following an appointment. Referrals and test results were managed in a timely way.

The service worked well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They concentrated on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately. Safeguarding policies were known to staff, who were appropriately trained in safeguarding procedures. Staff were supported to recognise safeguarding concerns and follow a clear, step‑by‑step response process, including what immediate action should be taken where there was risk and how to maintain accurate record‑keeping. Although the provider had not needed to raise any safeguarding concerns, staff were familiar with the procedures and understood the appropriate actions to take should an issue arise. Regular training, supervision, oversight, and yearly policy reviews helped keep safeguarding systems effective, well-monitored, and compliant with legislation and national guidelines.

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.For example, through clinical processes including treatment planning discussions, expected outcomes and warning signs. People were also advised of when to seek further review and appropriate aftercare information was given. Emergency equipment was available and maintained. Staff could recognise a deteriorating person and knew of action to take. People were advised about risks related to their condition and actions to take if their condition deteriorated

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. 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. The service ensured people were cared for in a safe, well‑maintained environment that met the people’s needs. Risks within the care environment were identified, monitored, and controlled, including those related to premises, utilities and equipment. Equipment was routinely maintained, fit for purpose, stored securely, and used appropriately by trained staff to support the safe and effective delivery of care. Environmental risks, including equipment failure and external factors such as adverse weather, were managed through clear procedures to minimise disruption and harm.

The service did not always make sure there were enough qualified, skilled and experienced staff and recruitment records were not consistently complete. We reviewed 3 staff files during our onsite visit, and noted the files were missing references, health declarations and some unexplained employment gaps. However, the provider responded promptly following the inspection and provided assurances that a full audit of all staff files had been completed, with all missing documentation obtained and no risks to people’s safety identified. Training records were up to date, staff had received the appropriate induction, and staff were working within their scope of practice. Records for locum GPs, including references and DBS checks, were complete and well-maintained.

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 service had a designated infection prevention and control (IPC) lead and all staff had completed relevant training. Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks. The service had effective systems to prevent and control infection and protect people, staff and visitors. Hand hygiene facilities were well-maintained with suitable signage, equipment and supplies, and staff demonstrated clear understanding of infection control procedures, including the management of needle‑stick injuries. Infection‑related risks, including legionella, were assessed and monitored, with recent certification confirming low risk. The environment was clean and well-maintained, with suitable flooring in clinical areas. Cleaning schedules were consistently completed, and there were arrangements for spill management, occupational health support and Control of Substances Hazardous to Health Regulations (COSHH) compliance.

The service made sure 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 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 controlled drugs. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments. The service had effective systems to manage and respond to safety alerts and medicine recalls. The service had effective systems for securely handling and managing prescription stationery, which complied with national counter-fraud guidance. For example, blank prescription stationery was stored securely, with access controlled through locked storage behind the reception area and additional secure storage in a locked room. The service used printed prescription paper pads; all pads were locked away and were individually protected with holographic stickers. Completed prescriptions awaiting collection were also stored securely in locked facilities.