Primary Care 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 Good.

The service was previously in breach of legal regulation in relation to:

• People on high-risk medicines were not being monitored appropriately.
• Safeguarding registers were not accurate, and we found no formal process in place to ensure registers were up to date.
• The provider was unable to demonstrate they complied with the relevant safety alerts issued by the Medicines and Healthcare products Regulatory Agency (MHRA).
• Personnel records showed staff immunisation status was not recorded and no risk assessments had been completed to identify potential risks to patients or staff.

Systems were now in place to protect individuals from abuse and avoidable harm, with safety clearly prioritised across the service. The provider responded seriously to concerns and feedback from people using the service indicated they felt safe and well cared for. Safety incidents were investigated, and learning was used to identify shortfalls and prevent recurrence.

Safeguarding procedures had been reviewed and strengthened since the last inspection in August 2023 to protect those at risk and services were designed around individuals to support safe transitions between care settings. People were supported to understand their care, enabling informed choices that reduced the risk of harm.

Leaders ensured there were sufficient numbers of appropriately skilled staff in place to deliver safe care. 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.

Health and safety procedures were in place, and the premises were appropriately maintained. However, systems for monitoring patients’ health in relation to medicines, including those requiring regular review, required further improvement. We discussed our findings with the leadership team during the assessment and areas we identified for improvement were promptly addressed and actioned. An update on what actions had been taken was provided which demonstrated risks had been mitigated.

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.

Since the last inspection in August 2023, 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.

New processes had been introduced to ensure complaints were investigated and acted on appropriately and we found significant improvements on how complaints were handled. We reviewed a random sample of complaints and found the provider had responded in a timely manner and had offered apologies to people. Lessons were learnt from individual complaints and shared with the practice team to improve the quality of care.

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. People told us they had enough time during their consultation, they felt involved in decisions about their care and treatment and had confidence and trust in the healthcare professional they saw or spoke to.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. There were systems in place for processing information relating to new patients. The service worked with other providers to deliver shared care and when patients moved between services.

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.

The provider told us there were processes in place that were monitored and managed to keep people safe. For example, the provider was part of the Primary Care Network (PCN) and attended regular meetings with other agencies across the locality to share and discuss information relating to patient care and treatment, for example, people on the practice palliative care register.

At the last inspection in August 2023, we found there were no effective systems in place to ensure safeguarding registers were appropriately maintained and there was a process in place for safeguarding meetings to ensure patients were being monitored and had received effective care. At this assessment we found significant improvements had been made. Safeguarding registers were well maintained with a list of vulnerable people in place. Clinical records we reviewed showed that they had been appropriately coded where safeguarding concerns had been identified. There were processes in place to follow up children and young people who were not brought to their appointments both at 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; 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.

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.

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.

Since the last inspection in August 2023, 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.

New processes had been introduced to ensure complaints were investigated and acted on appropriately and we found significant improvements on how complaints were handled. We reviewed a random sample of complaints and found the provider had responded in a timely manner and had offered apologies to people. Lessons were learnt from individual complaints and shared with the practice team to improve the quality of care.

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. People told us they had enough time during their consultation, they felt involved in decisions about their care and treatment and had confidence and trust in the healthcare professional they saw or spoke to.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Leaders told us that 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. Staff had been provided with training in health and safety related topics such as fire safety, infection control and manual handling. 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 the majority of equipment was regularly calibrated and electrical items were PAT (Portable Appliance Testing) tested. However, we found that the nebuliser had last been calibrated in February 2024 and there was no evidence at the time of the assessment that the due date of February 2025 had been acted on to test the equipment worked appropriately

There was a business continuity plan in place which was monitored and reviewed. All staff had completed health and safety training. This included basic life support and resuscitation training. 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.

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

There were processes in place for safe and effective staffing which had been reviewed since our last inspection. At the last inspection in August 2023, we found recruitment procedures required strengthening to ensure all the appropriate documentation was in place prior to employment. A recruitment policy was in place which included how the practice processed personal data in accordance with the General Data Protection Regulations (GDPR). We reviewed 4 personnel files and found appropriate checks such as previous employment record, proof of identity and clinical staff files had evidence to demonstrate that clinical registration 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.

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. We found the practice had reviewed their processes and could demonstrate how they assured the competence of staff employed in advanced clinical practice, for example, nurses and pharmacists.

There were clearly defined lead roles to support staff in carrying out their roles effectively and staff were supported by leaders. Staff were working within their agreed areas of competence with regular supervision in place.

There were staffing rotas to ensure there were adequate cover in place. On speaking with staff, we were told there were enough staff on duty to cover busy periods and for staff absences, however more nurses were required. We discussed this with the leadership team who told us they had plans to possibly increase the number of nurse practitioners and were in the process of securing a female GP from the PCN to work at the practice to provide more choice for people.

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 had relevant training. Cleaning schedules were in place and followed. An infection control audit had been completed in November 2024 and the practice had achieved 99%. 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 service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.The leadership team had reviewed their systems and processes since the last inspection to support the safe prescribing of medicines. The practice had employed a clinical pharmacist and also worked with the clinical pharmacists from the local PCN to monitor people and the prescribing of medicines. However, we found further strengthening was required to ensure all patients were monitored appropriately.

As part of the assessment, we carried out remote clinical searches. We reviewed the number of people aged 65 years and over who had been prescribed medicines to relieve pain and reduce inflammation called non-steroidal anti-inflammatory drugs (NSAIDs), who had not been prescribed a protective medicine to decrease stomach acid production (PPI) and reduce the risk of gastro-intestinal bleeding. The search identified 31 patients on these medicines who had not been prescribed a PPI. We reviewed a random sample of 5 clinical records and found 4 people were at risk as no PPI had been prescribed. A second search identified patients on medicines to treat heart failure who had not received the appropriate monitoring. The search identified 5 patients who needed a review. We reviewed each clinical record and found each patient required up to date monitoring. We discussed the findings of the clinical searches with the lead GP and following the assessment we received evidence to demonstrate that action had been taken to ensure all people identified had been contacted and plans were in place for a review to take place.

At the last inspection, the provider was unable to demonstrate they had effective processes in place to action safety alerts. At this assessment we found systems had been implemented which demonstrated there were clear processes for acting on safety alerts and evidence provided showed there were regular clinical meetings in place to discuss safety concerns and the actions taken.

Emergency medicines, vaccines and medical equipment had clear monitoring processes in place, however we found the storage of emergency medicines needed strengthening as they were stored in an unlocked cupboard and on the day of assessment, we found the room unlocked where the medicines were kept. On reporting our findings to the leadership team, action was taken to secure the medicines. 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 were told that there was only 1 person in the practice who knew how to use the data logger, which caused concerns when they were on leave. 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, however during the clinical searches we identified 55 people on 10 or more medicines that had not received a medicines review in the past 18 months. We reviewed a random sample of 5 clinical records and found no evidence that a review had been completed. We discussed our findings with the clinical team and following the assessment were provided with evidence to demonstrate actions had been taken to review the all the patients identified through the clinical search.

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. 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.