Church Crescent Medical Practice

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.

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

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 service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and had a system for reporting and investigating safety events. Lessons were learned to continually identify and embed good practice.

The service had a process to report incidents, near misses and safety events. The service had a significant events register and gave an example of where a significant event had been recorded and detailed the subsequent investigation and learning that was implemented following the event. There was a system to record and investigate complaints. The service provided an example of where a patient had been contacted to discuss a change in treatment plan and had talked through the issues to resolve concerns. The service told us that patients were triaged when they contacted the service and expectations were set so that only patients who could appropriately be treated were seen. Learning from incidents and feedback resulted in changes that improved care for others.

The service worked with people and referred to national guidelines 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 share information when this was necessary, for example, with the patient’s GP. Referrals and test results were managed in a timely way.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve this. The service had a process for sharing concerns quickly and appropriately.

The lead doctor was the safeguarding lead in the practice where they worked as an NHS GP and was fully conversant with safeguarding adults and safeguarding children protocols. The doctor had up to date adults and children safeguarding training to the appropriate levels. The service had safeguarding policies for adults and children. The service told us that patients were asked on the appointments booking form whether they had a disability or any additional needs, which was then coded on their clinical record.

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.

The lead doctor understood their responsibilities to manage medical emergencies and to recognise those in need of urgent medical attention. Clinical and electrical equipment, including emergency equipment, had been checked to ensure it was working safely. Patients were advised on risk related to their condition and actions to take if their condition deteriorated.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Health and safety risk assessments and audits had been undertaken and risk identified had been addressed. There was a business continuity plan in place which was monitored and reviewed.

The service consisted of one lead doctor and assured us that this provision was sufficient to meet the needs of the service. The lead doctor was qualified, skilled and experienced and worked well to provide safe care that met people’s individual needs. We found training was up to date.

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.

We saw that cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks. Feedback we received from patients who used the service was positive in relation to the cleanliness of the premises.

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.

The service involved people in reviews of their medicines and helped them understand how to manage their medicines safely. People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms or decline in their condition. Patients were able to telephone the service for advice post appointment and during out of hours, a message was on the answerphone directing patients to go to accident and emergency if needed.

We reviewed the clinical records for 11 patients, which were stored electronically on a secure network. Records were complete, accurate and up to date. Consultation notes demonstrated appropriate clinical decision making. The lead doctor followed established prescribing protocols and ensured medicines were prescribed safely. The service did not prescribe controlled medicines or high-risk medicines. Patients who required these medicines were referred back to their NHS GP.

During our site visit, we saw that emergency medicines were checked regularly and found them all to be in date. The service did not store some emergency medicines and we provided feedback for the service to complete risk assessments for these medicines including the reasons why the medicines were not required or if a substitute was used. The service had effective systems to manage and respond to patient safety alerts and medicine recalls.