Headstone Lane 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 our last assessment, we rated this key question as good. At this assessment, the rating has remained good. There was a proactive and positive culture of safety based on openness and honesty, in which concerns about safety were listened to, safety events were investigated and reported thoroughly. We saw evidence lessons were learnt to identify and embed good practice. There were processes in place for managing emergencies and safety netting measures embedded in the triage system to manage clinical risk. Premises and equipment were managed safely with an overarching business continuity plan which had been recently tested for effectiveness. There were safe recruitment practices with a learning and development programme in place to support staff.

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.

Patients we spoke with told us that when they have complained or given feedback about their concerns the practice told them they had investigated the issue and where possible had made changes.

There was access for patients to a friends and family form in the practice and on the practice website to understand patient experiences. We noted the practice had received 4 complaints in the last year. We saw evidence they had all been investigated and patients were informed of outcomes. In the reception area we saw information for patients about the complaint's procedure.

The practice staff told us they learned and made improvements when things went wrong. Staff told us they knew how to identify and report concerns, safety incidents and near misses. They told us and we saw evidence of learning and dissemination of learning to staff. Staff confirmed they could attend regular meetings held face to face and via a video link. Minutes were available for those unable to attend. Feedback we received from staff was positive about the learning culture within the practice.

The practice had systems and processes in place to record and manage any safety events in a timely way. They had a significant events policy and a reporting process for staff to raise concerns. There was a culture of learning with staff encouraged to report concerns for the whole practice team to learn. The practice demonstrated how they investigated, identified learning, and made any improvements that were required. We reviewed some ways the practice shared learning with staff such as team meetings, where minutes of meetings were taken which demonstrated a formal approach to managing learning. The practice had a complaints policy in place and information accessible to patients. The complaints we reviewed showed they were recorded, investigated and patients received a final response which included contact details of the Parliamentary Health Service Ombudsman if they wanted to escalate their complaint. Learning from complaints was identified and monitored to completion in a timely manner.

Patients and patient representatives we spoke with gave positive feedback in relation to referrals being made appropriately and being supported during waiting times to be seen by other services.

Staff told us they had the information they needed to deliver safe care and treatment. Individual care records, including clinical data, were written and managed securely and in line with current guidance and relevant legislation. Staff told us reviews were undertaken by the practice to ensure that systems and pathway guidelines were adhered to.

We received positive feedback from partners we spoke with in relation to ensuring safe systems of care, including when patients are receiving care and treatment from a range of services.

There were systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment. There was a documented approach to the management of test results, and this was managed in a timely manner. Referrals to specialist services were documented, contained the required information and there was a system to monitor delays in referrals.

The practice team had effective systems and processes in place to manage and respond to national patient medicine and safety alerts. Leaders and members of the medicines team at the practice explained how this worked to assure patient care and treatment safety.

Patients did not raise any concerns about safeguarding during the assessment. We saw evidence the practice had processes in place for safeguarding patients including a safeguarding register.

Staff told us they were aware of the practice and local safeguarding policies; they knew who the practice safeguarding leads were and how to report any concerns. There was evidence of, and staff confirmed they attended regular meetings where safeguarding discussions took place.

We received positive feedback from partners on how the practice’s proactive approach to safeguarding kept vulnerable patients safe. For example, regarding referrals, assistance with following up patients and effective information sharing.

The practice had clear systems, practices and processes in place to keep patients safe and safeguarded from abuse. These were clearly communicated to staff. Partners and staff were trained to appropriate levels for their role. There were system alerts to identify vulnerable patients on their medical records.

Patients spoke positively about how the practice ensured care met individuals’ needs and enabled them to do things that mattered to them. We spoke with a member of the patient participation group who told us the practice were open to discussing any concerns raised in respect of safety.

Staff told us there was an effective approach to managing staff absences and busy periods. They told us emergency equipment and medicines were easily available, and they were routinely checked. They confirmed they had received additional training such as recognising patients whose may have symptoms of deteriorating health.

There were effective arrangements for supporting patients to identify manage and mitigate risks. The practice had guidance for staff to identify and escalate risk to an appropriate clinician and staff had also received appropriate training. The practice had a clinical triage and on the day appointment team, where patients with urgent needs were triaged, responded to, and supported as appropriate.

Staff told us there were systems, practices and processes to keep patients safe. Issues identified from risk assessments and safety checks were escalated to the management team, logged and monitored to completion.

During our visit we observed the practices to be clean and uncluttered. Fire exits were clear and fire safety equipment easily available.

The practice demonstrated a proactive approach to using risk assessments to identify and mitigate risks. For example, we reviewed completed risk assessments which included health and safety and fire risk. Risks had been identified and actions taken to mitigate the risk The practice had arrangements to ensure business continuity in a range of circumstances, which included extreme weather conditions.

Patients told us they received support from staff at the practice in a timely way. They told us they found staff knowledgeable and well trained.

Staff told us there was an effective induction system for temporary staff tailored to their role. There were enough staff to provide appointments and prevent staff from working excessive hours.

Staff who were responsible for specific clinical interventions, for example reviews of patients with long-term conditions, cervical screening, and childhood immunisation, told us they had received role specific training.

The practice had clear processes and demonstrated that recruitment checks were carried out in accordance with regulations including for locum staff. All new staff received an induction programme which included role specific areas of work.

The practice was able to demonstrate that staff had the skills, knowledge, and experience to carry out their roles. Staff who were responsible for reviews of patients with long-term conditions had received specific training. Staff had completed training deemed mandatory by the practice, which included for example, infection prevention and control, equality and diversity and safeguarding training, appropriate to their role.

Feedback we received from patients was positive in respect of the cleanliness of the environment.

Staff told us they were aware of who the leads were and had no concerns about the infection prevention and control (IPC) processes. There was a lead for IPC.

Staff told us there were systems in place for dealing with specimens and bodily fluid spills. A full IPC audit was completed annually. Where improvements were required, these had been actioned, or there was a plan in place.

During our on-site visit to each site, we observed the practices to be clean and tidy. We found systems in place for cleaning of equipment within the clinical rooms. The storage of medicines was managed appropriately. We did not identify any concerns relating to infection prevention and control.

The processes in place had ensured appropriate standards of cleanliness and hygiene were met. Staff had received training and had carried out a detailed infection prevention, and control (IPC) audit. They had systems to monitor actions identified had been completed.

Records confirmed the practice was proactive in regular reviews of patients’ medicines. When acute medicines such as antibiotics were required, the practice organised these in a timely way. Patients we spoke with told us they were involved in regular reviews of their medicines.

Leaders and staff were able to demonstrate there were embedded processes to ensure medicines were managed safely. Staff told us there was a recall system for patients. Regular searches and audits were in place to ensure the practice delivered timely reviews. Clinical staff were appropriately trained and we saw evidence of ongoing medicine reviews.

Practice staff showed us via their clinical system that they had systems and processes in place to effectively monitor and manage patients’ medicines, including medicines which required additional monitoring. The practice held appropriate emergency medicines, and risk assessments were in place to determine the range of medicines required. There was a system in place to monitor stock levels and expiry dates. Vaccines were appropriately stored, monitored, and transported in line with the United Kingdom Health Security Agency (UKHSA) guidance to ensure they remained safe and effective.

The practice had systems for the appropriate and safe use of medicines, including medicines optimisation.

There was a process for reviewing patients’ health in relation to the use of medicines including medicines that require monitoring and systems were in place to ensure appropriate monitoring and clinical review prior to prescribing.

There was a process for the safe handling of requests for repeat medicines and evidence of effective medicines reviews for patients on repeat medicines. Clinical staff approved all medicines added to the prescribing page before any were issued. Medicines prescribed in hospital were added to the clinical records.

As part of the assessment, we conducted searches on the practice clinical system and reviewed a selection of patients’ records. There was a process for monitoring patients’ health in relation to the use of medicines including medicines that require monitoring for example, warfarin, methotrexate and lithium. We reviewed some patient records and found there was appropriate monitoring and clinical review prior to prescribing the medicines for all patients taking these medicines.