Scott Arms 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

At the last inspection, we found that not all safety alerts were actioned appropriately, processes for the management of people on high risk medicines and the monitoring of vaccine fridge temperatures were not embedded. At this assessment we found some improvements had been made and the practice had taken action to ensure high risk medicines and vaccine temperature recording was effective, however during the remote clinical searches we found safety alerts still had not been fully acted on. We also found recruitment processes were not followed in line with practice policies and there were no effective systems for the monitoring of staff training. Following the assessment, we received evidence to demonstrate that systems were being reviewed to mitigate risk.

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.

The practice had a significant events policy and a reporting form which was accessible to all staff members. The practice followed their significant events policy and discussed events and incidents during team meetings and learning was shared with staff. The practice had a duty of candour policy and involved people when managing significant events and errors. The practice had a clear system in place to record and investigate complaints. From the sample of complaint records we reviewed; we found the practice responded to people’s complaints in a timely manner. The practice offered apologies to people, lessons were learnt from individual concerns and complaints and action was taken as a result to improve the quality of care.

We found safe systems of care, in which safety was managed and monitored. For example, there was a system for processing information relating to new people including the summarising of new clinical records and there were systems in place for referrals to appropriate services, which was managed in a timely way. There was a documented approach for the management of test results.

On reviewing the clinical system we found outstanding tasks dating back to 2021. The tasks showed there were 9 tasks dated 2021, 40 tasks dated 22 and 69 tasks outstanding for 2023. Further review showed the tasks appeared to be messages, however we were unable to gain assurances that there was an effective system in place for clearing messages that had been actioned.

There were policies and processes in place to keep people safe and safeguarded from abuse. The practice had a safeguarding lead for adults and children the practice held a safeguarding register and clinical records we reviewed showed that they had been appropriately coded where safeguarding concerns had been identified. Clinical system alerts were used to identify people who were at risk of harm or abuse. There were processes in place to follow up children and young people who were not brought to their appointments both at the practice and for secondary care appointments. Safeguarding meetings were held on a regular basis to review people at risk and community teams were invited to ensure information was shared appropriately for the care of people with safeguarding concerns. On reviewing staff training records we identified gaps in safeguarding training that had not been updated. Following the onsite assessment we received evidence to demonstrate that an email had been sent to all staff of training to be completed. We were told by the management team that only team leaders carried out the role of chaperoning, however administration/reception staff confirmed they also undertook this role. There was a policy in place for the renewal of DBS checks, however this was not being followed. We found that many of the DBS checks had not been reviewed in the past 10 years, however the practice policy stated that if a DBS was not in place a risk assessment would be completed, we found no risk assessments were in place. The policy also stated that existing staff had to complete an annual declaration to confirm that there had been no criminal activity since the issue of the DBS certificate. We found no evidence to demonstrate that annual declarations had been completed. 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.

Leaders told us that they worked with services locally to understand and manage risks. For example, there were regular primary care meetings held with other agencies to work holistically so that care met patients’ needs and services managed care holistically. The practice also had registers in place to support those patients who were vulnerable or who had mobility or communication needs.

There were processes in place to ensure the practice prioritised care for their most clinically vulnerable people, however we found no evidence to demonstrate that staff had completed sepsis awareness training to ensure they were able to direct people who needed to seek further help and what to do if their condition deteriorated. We found there was no guidance available for call handlers on what was classed as urgent or routine and no documents signposting staff on where to direct people and the appropriate clinician they required.

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. Systems were in place for the regular checks of fire alarms, extinguishers and fire evacuation procedures. Risk assessments were in place to identify potential risks and we saw evidence to demonstrate that actions identified had been actioned to mitigate risk. Evidence provided by the practice showed equipment was regularly calibrated and electrical items were PAT (portable appliance testing) tested. We found the practice had not followed their security policy in relation to the changing of internal door codes. The policy stated these should be changed every 6 months or on the leaving of staff members. We found that the practice had recently had a number of staff leave, however none of the door codes had been changed. This posed a risk to the security of the premises. Following the onsite assessment we received an updated policy which showed door codes were to be changed every 12 months and if a member of the team left the practice, codes had to be changed within 24 hours. Further evidence demonstrated that the premises were secure with 24 hour surveillance in place and motion activated alerts in place which notified the leadership team of any potential risks.

Consulting rooms were available across two floors of the buildings and access was available to the second floor by lift and stair access. The practice had an evac chair in place to support people who were unable to use the stairs if their was an emergency; however online training had been completed, but there had been no face to face training with the chair following the online training to ensure staff were aware of what actions to take in an emergency.

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 a range of personnel files and found gaps in appropriate checks such as proof of identity, induction checklist and DBS checks. We found some clinical staff files had outdated evidence to demonstrate that clinical registration checks had been reviewed. Personnel folders were well unorganised and there was no systematic approach to ensure that personnel folders were managed appropriately.

We found staff immunisation status records were not in place for all staff. Immunisation status for all clinical staff was not recorded appropriately and there was no risk assessment for non-clinical staff who had not received the Hepatitis B vaccine to demonstrate potential risks of infection had been considered for both staff and people using the service.

We found that processes were in place for the supervision and oversight of staff with access to regular appraisals, clinical supervision and staff were supported to meet the requirements of professional revalidation. We reviewed a random sample of appraisals and found they contained minimal information about the individual and their achievements or areas of development and no evidence of training needs.

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 no completed assessments in place for the control of hazardous substances. We also found there was no regular cleaning schedules that had been completed and signed off to demonstrate cleaning had taken place. An infection control audit had been completed in February 2025, the practice had achieved 100%. The infection control audit showed there was a nominated lead for infection control, however we found that the nominated lead had left the practice and there had been no forward planning to replace them. At the time of the onsite assessment, one of the managers was taking the lead, however there was no clinical staff overseeing infection control. The audit also confirmed there was alcohol hand rub available, however we found 2 empty bottles in reception and this had not been identified by staff and replaced. Cleaning rotas were in place, but these had not been signed off to demonstrate that cleaning had taken place.

Due to the unorganised training processes in place, we were unable to gain assurances that all staff had completed infection control training relevant to their role.

Clinicians made appropriate and timely referrals in line with protocols and up to date evidence-based guidance. There was a system in place to ensure all information including documents, laboratory test results and cytology reports were reviewed and actioned in a timely manner. We found that test results were managed in a timely way and all workflow was followed up and actioned appropriately. Our review of clinical records in relation to the clinical searches identified that care records were managed in line with guidance and legislation. The practice had systems for monitoring two week wait referrals, which included daily monitoring of the digital dashboard to ensure specialist input has been actioned within the 14 days target. Evidence provided showed the practice had achieved 100% compliance of 2 week wait referrals. Multidisciplinary meetings were held with other agencies to share and discuss information relating to care and treatment, for example, those on the practice palliative care register.

The provider shared information to demonstrate that evidence from the Integrated Care Board (ICB) showed the practice was 12% below the Sandwell average for emergency admissions for people with asthma and chronic pulmonary obstructive disease (COPD) and 98% of patients with urgent exacerbations were seen within 4 hours of requesting an appointment. Further evidence provided showed 95% of people had received a structured annual review during 2024.

Further reviews of the clinical registers showed the majority of people were up to date with the monitoring of their health conditions. The findings of the clinical searches were discussed with the clinical team for the appropriate action to be taken. We found that the practice had taken action to review safety alerts and during the clinical searches identified 4 people who were taking a medicine that an alert had been issued for, due to the potential risk of a rare but potentially life-threatening infection that would require urgent medical attention. At the time of the assessment we found no evidence to demonstrate that people on this medicine had been informed of the risks involved and what actions to take if they became unwell, however following the assessment we were advised that the 4 people we had identified were new to the practice and the practice had acted on this alert when the patients had registered. We found blank prescriptions in an unlocked area within the administration office and no processes in place to ensure the safety of the prescriptions. Following the onsite assessment we received confirmation that the blank prescriptions had been removed to a secure area and training had been provided to staff. The incident was planned to be discussed at the next team meeting.