Al-Fal Medical Group - Pikes 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

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 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Al-Fal Medical Group - Pikes Lane Medical Centre had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

People felt supported to raise concerns and felt staff treated them with compassion and understanding.

Representatives from the Patient Participation Group (PPG) felt the provider took concerns seriously and proactively made improvements to the service. Managers encouraged staff to raise concerns when things went wrong. During staff meetings, the whole team discussed and learnt from clinical and safeguarding issues. Staff felt there was an open culture, and that safety was a top priority. The provider had processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Learning from incidents and complaints resulted in changes that improved care for others.

Al-Fal Medical Group - Pikes Lane Medical Centre 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.

There were systems in place for processing information relating to new patients. The service worked with other providers to deliver shared care and when patients moved between services. 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 that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations.

Al-Fal Medical Group - Pikes Lane Medical Centre 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.

People told CQC that their care and treatment was discussed with them, they confirmed doctors, nurses and other staff made sure they knew how to manage their condition and what to do if they failed to improve.

Emergency equipment was made available in a communal area, shared with other providers within the same building, and was maintained by an external contractor.

Staff could recognise a deteriorating patient and knew of action to take. Patients described instances when the GP gave advice to ensure they were effectively triaged when contacting emergency ambulance services. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

All staff had been trained in emergency first aid appropriate to their role.

Appointment booking staff had completed triage training to ensure specific questions were recorded correctly. This was so the appointment system prompted the most appropriate type of appointment and signposting people to alternative clinical care.

Al-Fal Medical Group - Pikes Lane Medical Centre detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Contracts were in place to ensure the premises were maintained. Health and safety risk assessments and audits had been undertaken and risks identified had been addressed. We saw that all checks and calibrations needed were up to date.

There was a business continuity plan in place which was monitored and reviewed. We also observed that all areas, including public areas and seating looked in good repair.

Al-Fal Medical Group - Pikes Lane Medical Centre made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

There was a range of clinical and non-clinical roles within the practice. We found training was up to date, learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence. Safe recruitment practices were followed.

People told us staff were knowledgeable, competent and good at carrying out their roles. Staff told us they were supported to increase their knowledge and learn new skills for the benefit of patients and in response to changes in best practice guidance and new techniques.

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.

The practice was working towards appointing a designated infection prevention and control lead. Staff had had relevant training. Cleaning schedules were in place and followed. The provider had worked with the community infection prevention and control team in order for audits to be conducted, and had evidenced changes resulting from audit scores.

The service in the main 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 always involved people in planning their medicines regime when contact was made.

People told us that staff involved them in reviews of their medicines and helped them understand how to manage their medicines safely.

People told us they knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms. People especially praised the time taken by the pharmacists at the service to provide information, review medicines, make changes and give advice about reducing side effects.

We observed processes in place concerning management of the storage, administration and recording of medicines that would keep people safe. Staff managed prescription stationery appropriately and securely.

By looking at information available through running a clinical search to check on how patients on particular medicines were looked after, we were able to check how well the service managed medicines. For example, whether people were invited for blood checks, or heart monitoring checks, or were told of special risks due to their age or gender. We also looked at whether medicines prescribed were reviewed in response to special messages sent called alerts.

The clinical searches revealed that some of the required checks had not always been completed in a timely manner. The provider sent evidence of the changes put in place and an action plan to ensure medicines optimisation would immediately improve and be more stringently monitored.

The clinical searches showed processes for dealing with alerts were in place and staff followed protocols such as responding to medicine alerts and following best practice guidelines to ensure they prescribed medicines safely. Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring.

Records made about medicine management for patients needed to be reconciled. The clinical searches included checking what was written for each patient during the medicine review. The notes looked at did not always confirm the information and advice given or that the correct tests had been requested for patients. The provider discussed possible ways of ensuring all records available were reconciled and reflected the care and treatment provided to patients.

Medicines were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines. Waste medicines were recorded and disposed of appropriately including medicines returned by patients. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments.

Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. Prescribing data reviewed as part of our assessment confirmed this. For example, the number of antimicrobials issued by the provider was in line with local and national averages. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.