Bartley Green 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 investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff knew how to report any concerns they identified. Staff concerns were responded to promptly, with evidence of resulting changes. Staff told us about actions that had been taken following investigation of an incident and that feedback was given in clinical meetings. For example, the service reviewed the panic button function after a fault was reported and this was communicated to all staff.

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.

The service worked with other providers to deliver shared care and when patients moved between services.

There was a robust system to summarise new patient records, at the time of the inspection there were no outstanding records to be summarised. Clinical test results had effective processes, by the service, in place to be managed efficiently.

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 had a designated safeguarding lead and administrator who maintained a list of vulnerable people and acted on concerns working in partnership with other organisations. Staff we spoke with demonstrated that professional curiosity was embedded in daily practice, positively impacting patient outcomes.

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.

Emergency medicines and equipment were available and maintained. Staff could recognise a deteriorating patient and knew what action to take. Patients were advised on risks related to their condition and the actions to take if their condition deteriorated. For example, the service provided a rescue pack for patients with long term lung conditions. This included medicines and advice on when to seek further medical assistance.

Appropriate triage systems were in place to identify people who required an urgent appointment and to signpost people to alternative services when required.

The service 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. At the time of our inspection renovations were taking place, leaders had ensured that potential risks posed to people using the building during that time had been assessed and mitigated. The service showed us up-to-date fire risk assessments and had appropriate number of trained fire marshalls.

There was a business continuity plan in place which was monitored and reviewed.

The service 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 were 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, staff were given access to further continuous professional development opportunities and staff were working within their agreed areas of scope of practice. Staff files we reviewed showed that safe recruitment practices were followed, and all staff had appropriate clinical supervision.

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 had a designated infection, prevention and control (IPC) lead and all staff had completed relevant training. Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks.

On inspection we found carpet in one clinical room and fabric blinds in all clinical rooms which did not meet IPC standards however these were appropriately risk assessed and cleaned. When we raised this with the practice, they responded promptly and confirmed plans to address these issues as part of ongoing building renovations to achieve compliance with IPC standards.

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.

Staff 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. Staff received regular training, had competency assessments on medicines optimisation, and felt confident managing the storage, administration and recording of medicines. Staff managed prescription stationery appropriately and securely. 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. Medical gases, such as oxygen, were stored safely and required safety risk assessments were completed. The provider had effective systems to manage and respond to safety alerts and medicine recalls.

There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.

Non-clinical staff were able to clearly describe their roles and responsibilities when alerts on the clinical system indicated patients required follow-up appointments. They demonstrated an appropriate understanding of the actions required, including timely escalation to the clinical team where further review was necessary.