Old Road 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.

At our last assessment, we rated this key question as Good. At this assessment, the rating has changed to Requires Improvement.

At this assessment we found the service was in breach of legal regulation in relation to Regulation 12 - Prevent people from receiving unsafe care and treatment and prevent avoidable harm or risk of harm.

This service scored 44 (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 did not always have a proactive and positive culture of safety based on openness and honesty. They did not always listen to concerns about safety or investigate and report safety events effectively. We found no evidence that lessons were learnt to continually identify and embed good practice. We did not find evidence that staff were encouraged to raise concerns when things went wrong. Staff meetings were not held regularly, and safety concerns were not always discussed with the whole team. We did not find evidence of learning from incidents and complaints that resulted in changes that improved care for others. However, there was a system to record and investigate complaints. People using the practice services told us they thought they would be supported if they raised concerns, and felt staff treated them with understanding. The provider had processes for staff to report incidents, near misses and safety events.

There was no evidence seen at the practice to prioritise laboratory test results when received. This meant that people were at risk of not being safety netted when urgent treatment and follow-up was needed for their continuing health care. No procedure was seen to safety net people in need of urgent care and follow-up treatment for their continuing health care to keep them safe. However, on the day of the site visit we saw that the results received were being managed within 3 to 4 days. We were not provided evidence that the practice worked with people and healthcare partners to design, establish and maintain safe systems to ensure care was always managed and monitored. There were no environment health and safety risk assessments carried out at the practice to keep people safe. People told us they experienced continuity of care, including when people moved between different services.

We saw evidence on peoples records that the practice worked with people and healthcare partners to understand what being safe meant to them. Evidence seen showed they were protecting people’s right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The practice leaders told us they shared concerns appropriately. Safeguarding policies were in place and known to staff, who were trained to the level suitable for their role. The practice worked with the vulnerable people registered at the practice and acted on concerns working in partnership with appropriate local organisations.

People told us staff at the practice worked with them to understand and manage their healthcare risks. They also told us they were provided care to meet their immediate and on-going needs. Staff we spoke with told us they could recognise a deteriorating patient and knew what actions to take. People told us they were advised about the risks relating to their condition and actions to take if their condition deteriorated.

The service did not always detect and control potential environmental risks. The provider did not carry out environmental health and safety risk assessments at the practice. We also found the practice did not always make sure equipment, and facilities were well maintained. For example, the main medicine fridge had been broken for over 6 weeks when we carried out our site visit, and no actions had been taken to have it repaired or replaced. There had been no risk assessment to understand the need to replace or repair the fridge. This meant the 2 remaining fridges were overstocked, restricting the air flow around the medicines, this could affect the temperature control being constant to keep medicine safe. We also saw there was no second temperature check as guidance suggests for assurance of good temperature control within medicine fridges. Although there was a business continuity document in place we found this was not monitored or reviewed. We found no clinical chair or couch in the room used by the nurse in the branch surgery for clinical appointments, this had been moved to the main surgery to replace a broken couch. This meant that if people were feeling poorly either when having a blood test or because they were feeling unwell, they could not be placed in the recovery position or reclined if they fainted.

The practice staff records that we reviewed did not contain individuals training records, or clinical role specific qualifications, supervision, competency, or skills checks undertaken. Safe recruitment processes had not always been followed. There was no system in place to monitor and audit the required learning for staff to ensure people were supported by staff who were trained to meet their needs safely and effectively. Staff records reviewed showed no appraisals had been carried out for over a year, this included for new staff members, to understand their support and development needs. This placed people registered at the practice at possible risk of receiving unsafe care. Staff that we spoke with at the practice told us they felt there were enough qualified, skilled and experienced staff, and felt they were supported by leaders when they asked. However, they could not provide any documented proof of staff receiving effective supervision, training and development. Staff told us they worked well together as a team to provide care and treatment to meet people’s individual needs. We saw a range of clinical and non-clinical staff roles working at the practice.

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns promptly. Following an infection prevention and control (IPC) audit carried out by the local Integrated Care Board (ICB) on 31 July 2024 we found there had been no actions undertaken to rectify and mitigate the identified risks at that time. For example, we saw flooring in the clinical room had detached from several walls, there was a tear in an examination couch in room 9, the paint in the patient toilet was peeling off the walls. These issues had been identified during the IPC audit and represented IPC environmental issues. These environmental concerns increased the risk of acquiring an infection for people using the practice and its staff. There was no evidence that the risk of legionella infection was being checked regularly or monitored with appropriate mitigations put in place. The practice had a nominated IPC lead however, they had not been provided with relevant training to carry out their role effectively. We were told cleaning schedules were in place however, we were not provided evidence or assurance of these. No risk assessments or audits had been undertaken to identify possible cleaning or IPC risks. For example, regular handwashing audits, environmental audits or legionella water checks.

Medicine that did not need to be kept in the fridge was stored appropriately at the correct temperature. We found prescription stationery was appropriately stored securely, recorded, documented, and managed appropriately. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines, and vaccines. Staff stored and monitored medical gases, such as oxygen, safely. The provider had an effective system to manage and respond to safety alerts and medicine recalls. Antibiotic and antimicrobial prescribing data reviewed as part of our assessment confirmed the provider prescribed a higher number of antimicrobials than local and national averages. There was no program of regular clinical audits of prescribing to focus on improving prescribing habits, care, or treatment at the practice. Appropriate emergency equipment was available and maintained. Appropriate emergency medicine was available at the main practice site, however, there was inappropriate emergency medicine held at the branch practice site. The lack of appropriate doses of adrenaline to treat adults, children and babies had not been risk assessed by the provider. This placed people who use the practice at the branch site at risk of harm in an emergency situation. We also noted there was no resuscitation protocol guidelines at the branch site for staff guidance in emergency situations to administer the adrenaline.