The University Health 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 inspection, we rated this key question as requires improvement and issued a breach of Regulation 12 (Safe care and treatment) as there were gaps in systems and processes to ensure safe recruitment, premises, medicines management and the management of some patients with long-term conditions. At this assessment, we found the practice had made improvements to all areas of concern and is now rated good. We found the practice had a good learning culture and people could raise concerns. Managers investigated incidents thoroughly. There were systems in place to ensure people were safe and safeguarded from abuse. Staff understood and managed risks. The facilities and equipment met the needs of patients and were clean and well-maintained. Staff had the right skills, qualifications and experience. Managers made sure staff received training and regular appraisals to maintain high-quality care. There were systems and processes in place to support medicines management. A review of patient clinical records found that patients’ medicines management and treatment were safely managed by the practice.

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.

The practice demonstrated a proactive and positive culture of safety, based on openness and honesty. Leaders told us that they promoted a culture of learning and encouraged staff to report incidents openly. Staff were able to explain the process of how they would report an incident or who they would seek guidance from to do so. They told us they were encouraged to report incidents and felt confident to do this. The practice had systems and processes in place, underpinned by policies, to formally manage incidents and complaints. At this assessment we reviewed a selection of incidents and complaints and saw appropriate action had been taken and learning shared through meetings. We reviewed some recent meeting minutes, and we saw evidence that incidents and complaints had been discussed.

Leaders told us they worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. We found the practice had formal systems and processes in place to manage referrals, clinical correspondence, pathology results and medical record summarising. We observed that urgent 2-week wait cancer referrals were dealt with appropriately and a system was in place to ensure they were sent in a timely manner and that patients had attended for their appointment. Pathology results were actioned by clinicians and there was a system in place for when staff were absent. We saw incoming patient correspondence was appropriately managed and actioned, including changes to patients’ medications which was undertaken by the pharmacy team. Clinical records of new patients were mostly received by electronic transfer. Those that were received in paper form were summarised in the practice’s clinical record system. We saw that the practice had summarised 95% of patient records. The practice had completed an audit of the summarising process to ensure medical records were summarised in line with their policy.

The practice had systems and processes in place to identify, record and action safeguarding concerns, which were outlined in a safeguarding policy. One of the GP partners was the safeguarding children and adult lead. In addition, there was a GP deputy lead and a non-clinical administrator who were responsible for safeguarding-related recalls and workflow. This was overseen by the safeguarding lead. All staff we spoke with, and those who had completed questionnaires, knew who the safeguarding team were and how to access safeguarding policies.

Records showed that all staff had undertaken training for safeguarding children and adults, preventing radicalisation, Mental Capacity Act (MCA), Deprivation of Liberty Standards (DoLS), learning disability and autism awareness at a level relevant to their role. Staff we spoke with confirmed they had undertaken training and were able to give examples of how they would report and escalate safeguarding concerns.

We saw there were systems in place to follow-up on children with frequent attendance at accident and emergency, and when children had not been taken to secondary care appointments or for childhood immunisations. There were systems in place to identify vulnerable patients on their clinical records and staff were aware of this. As part of this assessment, we reviewed 2 safeguarding records and found evidence of safeguarding ‘pop-ups’ and appropriate coding.

The safeguarding lead attended external Kirklees safeguarding meetings and had regular internal link meetings with the local 0-19 years practitioner, which were documented.

Staff who acted as a chaperone were trained for the role and had received a Disclosure and Barring Service (DBS) check. At our on-site inspection we observed notices displayed in the practice to advise patients that a chaperone service was available, if required.

The practice worked with people to understand and manage risks and provided care to meet patients’ needs that was safe. At our on-site visit we observed that the practice was equipped to respond to medical emergencies, including suspected sepsis. The practice had undertaken a review of the emergency medicines available at the practice based on local context and the services they provided. A risk assessment had been undertaken to support these decisions. We reviewed processes around the management of emergency equipment and medicines and saw there were regular checks in place which were recorded. Records confirmed that staff had completed face-to-face basic life support (BLS). Staff feedback demonstrated that all staff were aware of the location of the emergency medicines and medical equipment, for example oxygen and the automated external defibrillator (AED). Non-clinical staff were aware of ‘red flag’ presenting complaints, for example patients with shortness of breath, and what action to take if they encountered a deteriorating or acutely unwell patient. Staff were aware of how to raise the alarm in the event of an emergency and told us they used the panic alarm system integrated into their clinical system.

The practice was located in a purpose-built medical facility. Patient services were delivered from the first and second floor, which were accessible by stairs and a lift. Entrance to the building was on the ground floor, which was predominantly covered parking. The facility was managed by the landlord who was responsible for some premises maintenance and building risk assessments. At our last inspection, we found the practice did not have a system in place to monitor the facilities management undertaken by the landlord on an ongoing basis to satisfy themselves that all areas were compliant. At this assessment, we found the practice had implemented a tracker to monitor the maintenance undertaken by landlord.

At our previous inspection, we found gaps in systems and processes to ensure safe premises as appropriate premises risk assessments had not been undertaken by the practice of the tenanted areas they occupied. At this assessment, we found risk assessments had been undertaken by the landlord and the practice, as appropriate, for fire, health and safety, Control of Substances Hazardous to Health (COSHH) and Legionella. We saw remedial actions from risk assessments had been completed. In addition, we found appropriate maintenance contracts in place which included the fire alarm system, fire extinguishers, portable appliance testing (PAT), calibration of medical equipment, gas safety, Electrical Fixed Installation Condition Report (EICR) and Lift Operations and Lifting Equipment Regulations (LOLER).

There was a record of regular fire alarm testing, and a fire evacuation drill had been undertaken in December 2024. The practice told us that these were undertaken 6 monthly. All staff had received fire awareness training and there were nominated fire marshals, who had been trained. There was appropriate signage in place, such as for fire escape routes and the fire assembly point.

At our previous inspection we found gaps in systems and processes to ensure safe recruitment of staff. At this assessment, we found the practice had reviewed their recruitment policies and had implemented procedures to ensure appropriate recruitment documentation was in place prior to the commencement of staff. In addition, there was a systematic approach to induction, training and appraisals. As part of our on-site assessment, we reviewed 2 clinical and 1 non-clinical staff recruitment file and found all relevant employment documentation in accordance with regulations were in place. For example, photographic identification, references, Disclosure and Barring Service (DBS) and professional registration checks. All staff were up-to-date with mandatory training identified by the practice and there were records of role-specific training. For example, cervical screening and immunisation. We saw that staff who had been at the practice for more than a year had received an appraisal. The practice provided consultation and prescribing audits of staff employed in advanced clinical practice, for example prescribing nurses.

Feedback from leaders and staff informed us that they had a good understanding of Infection Prevention and Control (IPC). There was a nominated IPC lead and policies in place. Staff knew who the nominated IPC lead was, how to access relevant polices and had received IPC training relevant to their role. On the day of the on-site assessment, we observed the premises to be clean, tidy and clutter-free. The cleaner’s cupboard was tidy and contained appropriate colour-coded equipment and cleaning materials. The arrangements for managing waste and clinical specimens kept people safe. We found posters around the practice including sharps injury, handwashing and clinical waste to support good practice. Appropriate personal protective equipment and bodily fluid spillage kits were available to staff. We spoke with the nominated IPC lead who told us they had dedicated time to undertake this role and had undertaken additional external training to support them in the lead role.

At our previous inspection, we found gaps in the recording of the immunisation status of some clinical staff in line with guidance. At this assessment, we found the practice had reviewed this as part of their recruitment processes. We reviewed 3 staff files and found a record of the individual immunisation status for staff.

At our previous inspection, we found aspects of medicines management, including medication reviews, repeat prescribing, the monitoring of patients prescribed some medicines and patients prescribed medicines subject to a patient safety alert, was not consistent. As part of this assessment, a CQC GP specialist advisor (SpA) conducted a series of remote clinical searches of patient records to assess the practice’s procedures around prescribing and medicines management. Overall, we found improvements since our last inspection and the practice had systems in place to ensure patients prescribed disease-modifying antirheumatic drugs (DMARDs) and medicines requiring monitoring were appropriately managed. With regards the 4 patients prescribed the DMARD Methotrexate, we did note the day of the week on which this medicine should be taken was not included on the prescription in line with guidance. After the assessment the practice confirmed that they had raised this with all clinicians who undertake medicines reviews to ensure this was included going forward. The practice also planned to audit that this was being undertaken in 6 months’ time.

We reviewed the systems and processes in place to receive, disseminate and act upon patient safety alerts. Overall, the findings of our clinical search indicated a structured approach. We highlighted 2 patients from the search for further review and received written feedback from the practice.

There was a process in place for the safe handling of requests for repeat medicines and evidence of medicines reviews for patients prescribed repeat medicines. We saw there had been 320 medication reviews for all ages in the last 3 months undertaken and we found a good standard of review.

At our on-site assessment we found vaccines were appropriately stored, monitored and transported in line with guidance to ensure they remained safe and effective. Medical gases, such as oxygen, were stored safely with appropriate warning signage. Staff had the appropriate authorisations to administer medicines, including Patient Group Directions and Patient Specific Directions. Blank prescription stationery was securely stored, and their use was monitored in line with national guidance.

Data showed that the practice had systems in place to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. We saw that the prescribing outcomes were better than national averages for 5 out of 6 prescribing outcomes. For example, the number of antibacterial prescription items prescribed was 0.24 (expected 0.82) and the percentage of antibiotic items prescribed that are co-amoxiclav, cephalosporins or quinolones was 3.2% (expected 7.8%).