Partners in Health

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 assessed all quality statements in the safe key question.

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

The service had a good learning culture and people could raise concerns. There was a proactive, systematic approach to managing safety. The leadership team investigated incidents thoroughly. Patients, staff and visitors were protected and kept safe. Staff understood risk and there was a proactive culture to identify and report risk. Staff were actively encouraged and appreciated for raising concerns about safety and ideas to improve. People felt part of a team where they can contribute towards safety and improvement. The primary response was always to learn and continuously improve, through discovery and shared learning meetings, Protected Learning Time (PLT) and impromptu feedback.

The facilities and equipment met the needs of people, were clean and well-maintained and any risks mitigated. There were enough staff with the right skills, qualifications and experience. Leaders made sure staff received training and regular appraisals to maintain high-quality care. Staff managed medicines well and involved people in planning any changes.

Services were planned and organised with people and communities, including those from minoritised groups and those where outcomes are known to be poorer. This was done in a way that improved their safety across care journeys, and safety was monitored collaboratively.

Information and intelligence were actively sought out to demonstrate that people are always safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination. Their liberty was protected where this was in their best interests and in line with legislation.

People were given information and leadership that supported them to make choices which balanced risks of harm with positive choices about their lives.

This service scored 81 (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 strong proactive, consistent, and positive safety culture based on openness and complete honesty. Staff actively listened and responded to safety concerns, followed clear processes for reporting incidents and investigated issues thoroughly, maintaining transparency in reporting over time.

Leaders encouraged staff to raise concerns when things went wrong. Staff received feedback and learnt from incidents through individual discussions and team meetings. Teams reflected on events and shared learning to improve safety and care. Staff described an open culture where safety was prioritised. The provider had systems for reporting incidents, near misses and safety events. Patient feedback was actively encouraged, and complaints were recorded and investigated thoroughly. All patient feedback was reviewed, including verbal feedback, to identify trends and themes that informed service improvements. Feedback was shared with staff and GPPS survey results appeared in their internal news bulletins, to highlight any training needs. Evidence showed that incidents, complaints, and feedback were routinely discussed during Protected Learning Time (PLT) meetings, multi-disciplinary team meetings (MDT) and clinical team meetings to review outcomes and maximise learning to support change. We saw documentation of clinical learning events. Staff, patients, stakeholders, and partners raised safety concerns and improvement ideas freely. Staff reported that leaders consistently demonstrated and reinforced the value of learning.

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.

Staff held regular MDT meetings to review the care of patients with complex needs and those approaching end-of-life. These meetings ensured care remained holistic and well-coordinated. Clinicians followed established pathways for diagnosis, treatment, and referral to specialist services. A dedicated member of staff managed referrals to secondary care, including urgent two-week wait referrals for suspected cancer, promptly and appropriately. Staff processed workflows and correspondence, including communications from secondary care such as discharge summaries, efficiently to maintain continuity of care.

Receptionists were trained in the local care pathway system, overseen by a duty GP. Staff carried out urgent needs assessments, allocated appointments, and signposted to other support networks. For example, social prescribing practitioners, and the Gloucestershire Primary Care Network (PCN is a group of local GP practices that collaborate with other health and social care providers to deliver more integrated and accessible services to their communities). This supported them to direct patients effectively, based on their needs, and promote preventative healthcare.

Partners who accessed GP services provided positive feedback, including a local care home that described a responsive and compassionate relationship with the service. Staff worked collaboratively to deliver timely, person-centred care, supported by regular communication and prompt clinical input. A multi-disciplinary approach was maintained, involving a care home liaison team, physiotherapist, and mental health professionals, reflecting the service’s commitment to a coordinated approach to continuity of care, and improved patient outcomes.

The service worked well with people and healthcare partners to fully understand what being safe meant to them and the best way to achieve that. They had a clear focus on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They always shared concerns quickly and appropriately.

There were a safeguarding policy and process for reporting safeguarding concerns and a comprehensive system, with clear roles and responsibilities, through which safeguarding risks were proactively identified, managed actioned and reduced. Staff spoke confidently about the safeguarding process and were appropriately trained in safeguarding procedures. Staff spoke about a distressing safeguarding incident that had taken place. The service used this opportunity to review the wellbeing of the team and arranged additional external training from a recognised body to support staff. Staff cited this example of how leaders take staff concerns seriously and actively support their development and wellbeing.

MDT meetings were held involving all clinical staff and external partners. The service worked closely with a range of professionals including school nurses, health visitors, district nurses, social prescribers, GPs, and relevant nursing staff. Staff were also invited to external safeguarding meetings involving the police and Gloucestershire Drug and Alcohol Service (GDAS), demonstrating strong multi-agency collaboration.

A coding system was used to identify and monitor vulnerable patients. For example, when ambulance reports indicated a risk of neglect, these were forwarded to designated safeguarding leads, who ensured the patient’s record was appropriately coded. Safeguarding alerts were added to the clinical record system when relevant, ensuring all team members remained aware of ongoing concerns and could respond appropriately. This included information relating to household and family safeguarding contacts. The service maintained an up-to-date list of vulnerable individuals and acted on concerns in partnership with external organisations to safeguard patients effectively. This information was also shared with out-of-hours services to support continuity of care and safeguarding oversight. A similar process was followed for children who missed immunisations or hospital appointments, with staff liaising with health visitors and school nurses to assess any safeguarding concerns.

The service had comprehensive systems to monitor and proactively improve how the Mental Capacity Act (MCA) was applied, and decisions were communicated with all relevant people and organisations involved in the person’s care. This included the Deprivation of Liberty Safeguards when applicable. Staff were confident about using the MCA and made sure that people’s human and legal rights were respected.

Staff identified designated safeguarding leads for both adults and children and demonstrated confidence in escalating any safeguarding concerns. They spoke of how they would act if they suspected a patient’s safety was at risk.

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 signs of high-risk, red flag symptoms (signs of serious illness or injury that require immediate medical attention) and the deteriorating health of patients and were knowledgeable regarding the appropriate action to take. All staff were up to date with basic life support training and received training on emergency symptoms including sepsis. Emergency medicines and equipment were available at both sites and were regularly maintained and audited. An electronic alert located on the digital healthcare record system would, when needed, summon support for staff. There was a system to provide support from a Duty Doctor, which was available to staff. Staff we spoke with provided examples of co-ordinated responses between clinical and non-clinical staff to manage medical emergencies. Weekly MDT meetings were held with the Lead GP, where examples of incidents and learning opportunities were discussed.

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

As part of this inspection both the main practice Pavillion Family Doctors and the branch site, St James were visited. There were contracts to ensure the premises were cleaned and maintained regularly.

There was a business continuity plan which was monitored, reviewed and contained information to manage unforeseen emergencies.All staff were up to date with fire safety and health and safety training. Lead roles were clearly defined.

Both sites were well-maintained, clean, and free from clutter. Clinical rooms and waste bins were appropriately equipped and maintained. Fire equipment checks, fire drills, and electrical safety testing were documented and up to date. The service conducted a range of risk assessments and audits, including fire, and electrical systems. Recent Planned Preventative Maintenance (PPM) survey reports were available for both sites. These reports assessed the integrity of the premises and supported futureproofing of the buildings to ensure continued safe and effective service delivery. This report had been reviewed and fully understood by the service with actions and outcomes pending at the time of assessment.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. Although some staff feedback indicated that appointment demand sometimes exceeded manageable levels, they worked together well to provide safe care that met people’s individual needs.

The service demonstrated a proactive, and positive safety culture based on openness and honesty. Staff, patients, stakeholders and partners were actively encouraged to raise concerns about safety and ideas to improve.

The service is part of a larger PCN and were supported to deliver essential services when needed.

The service identified, assessed and managed the risk of infection, with clear roles assigned including a designated infection prevention and control (IPC) lead, who supported staff and worked together to detect and control the risk of IPC concerns.

An IPC Board Assurance Framework was completed for both sites by the IPC lead and was regularly reviewed. Staff had received training relevant to their roles. Senior staff attend Southwest IPC meetings to maintain awareness of best practice. The IPC policy was accessible to all staff and was under regular review. Staff knew how to manage clinical waste and specimens. All nurses were given time at the end of each clinic day to empty clinical waste bins to maintain a hygienic workspace. External bins were secured in a locked area. Cleaning schedules were followed, and the service met with the external cleaning company regularly to review the completed cleaning audits and discuss any issues to maintain standards. Staff knew where spillage kits were kept, and which staff were trained to use them.

Regular checks were carried out of clinical curtains, bacterial filters in spirometry equipment, sharps bins, clinical waste management, premises and equipment. Stock checks of medicines and fridges were completed weekly. On the day of inspection, we observed the service was visibly clean and tidy. Personal Protective Equipment (PPE) was available and there were hand washing facilities and clinical wipes in all clinical areas.

Staff vaccinations were kept up to date in line with the latest UK Health Security Agency (UKHSA) guidance. An isolation room was available where a patient suspected of having an infectious disease was placed. The room was ventilated and deep cleaned prior to it being used again.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

Clinical staff received regular training, and competency assessment on medicines optimisation, and felt confident managing the storage, administration and recording of medicines.

The service had a clinical pharmacist who collaborated with the GPs in the service and were responsible for medicines management, supporting safe prescribing, medication compliance, and long-term conditions (LTC) reviews. A nurse visited the dementia care home weekly to review long-term conditions, and a GP conducted monthly walk-around visits. The lead nurse completed monthly home visits for housebound patients, which included foot checks and, more recently, COVID-19 and flu vaccinations.

Safety alerts were highlighted on the intranet homepage, and staff signed up to alerts relevant to their roles, supporting a safe and informed prescribing service. Staff were able to scan a QR code from their phones and complete required tasks reducing the risk of human error when imputing data.

The service regularly audited non-medical prescribers (NMP) (healthcare professionals, such as nurses and pharmacists, who can prescribe medicines but are not GPs) to ensure medicines prescribed were necessary, correctly prescribed and monitored when needed.

The service had policies for the management of medicines and a process for authorising staff to administer medicines including Patient Group Directions (PGD) and Patient Specific Directions (PSD). PGDs provide written instructions for the supply or administration of licensed medicines for a defined clinical condition, while PSDs were issued by prescribers for named patients. During the inspection, we reviewed a sample of PGDs and PSDs and found they had been completed correctly.

The service received patient lists from hospital services for re-vaccination schedules, including interval guidance. Where PGDs were not present, clinical staff created PSDs and tasked the administration team to complete and document on records. Nurses conducted phone consultations to assess immunisation needs, and these were flagged as tasks and directed to relevant clinical staff for authorisation. The service notified the hospital of the immunisation plan and guidance. PSDs supported immunocompromised (when the immune system is weakened, making a person more vulnerable to infections and cancer) patients and their families, demonstrating effective multi-disciplinary working and robust medicines governance.

Medicines including controlled drugs were stored securely and at correct temperatures.

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 carried out regular clinical audits focused on improving prescribing safety and effectiveness. Staff followed established processes to ensure people prescribed high risk medicines received appropriate monitoring. As part of our assessment a number of clinical record searches were undertaken by a Care Quality Commission (CQC) GP specialist advisor. These searches were visible to the service. The searches identified some shortfalls in the management of medicines and in the management of LTC. Following the inspection the provider reviewed the affected patients who were contacted and invited for a review.