Birchwood Surgery

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 under our new methodology for this service. This key question has been rated as requires improvement.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider's processes for staff to report incidents, near misses and safety events required strengthening. There was a policy and system in place to record and investigate complaints and concerns. Managers encouraged staff to raise concerns when things went wrong. During weekly staff meetings, the whole team discussed and learned from clinical issues. Staff felt there was an open culture. We reviewed 2 samples of complaint responses and identified that both complaint responses had details of the Parliamentary and Health Service Ombudsman. Complaints were documented with actions that had been taken. However, we found the duty of candour policy was outdated by 4 years. The provider had acknowledged the need for a more formal approach to policy reviews. Significant events were formally logged. We reviewed the processes for Medicines and Healthcare Products Regulatory Agency (MHRA) safety alerts and found it to be effective. Our remote clinical searches identified 181 out of 477 people who had been prescribed an antiplatelet medicine with no gastric protection. This medicine poses a risk of haemorrhagic bleeding. Once informed, the provider immediately reviewed these service users. Our remote clinical searches also identified 14 people prescribed a teratogenic medicine (medicines that can cause foetal abnormalities) who did not have effective contraception in place or an adequate annual risk assessment that was signed by 2 consultants.

The service did not establish and maintain safe systems of care and did not manage or monitor people safely. We identified that patients prescribed an anti-rheumatic medicine were monitored satisfactorily. We reviewed patients prescribed an anti-antagonist medicine and found that 22 out of 75 patients were at risk of a raised potassium level. We told the provider to review these patients immediately. We further identified 32 people with a raised HbA1C level of >75 indicating they were potentially diabetic and had not been correctly monitored or coded. We will continue to keep this under review to ensure embedded processes are operating effectively.

The service worked well with people and healthcare partners to understand what being safe meant to them. There was a safeguarding lead who was one of the GPs. In their absence, a suitably qualified and experienced GP was available for safeguarding issues. The practice did not conduct or attend multidisciplinary safeguarding meetings with external stakeholders. We reviewed the staff safeguarding training matrix given to us by the provider and identified that a number of staff members had not completed required adult or child safeguarding training at levels 1 or 2. The provider had a DBS policy, and this was included within their recruitment policies for adults and children. We found staff had received DBS checks appropriate for their role.

The service did not always work well with people to understand and manage risks.We found that some members of staff did not have up-to-date training in a number of areas including adult and child basic life support, chaperone and sepsis awareness. A training matrix required updating. Some staff were not aware of the signs of sepsis.We reviewed emergency medicines stored on site and all recommended medicines were available.

The service had a process to identify potential risks in the care environment. They made sure equipment, facilities, and technology supported the delivery of safe care. A fire risk assessment was completed in March 2024 and the provider had updated their risk assessment action log. Contracts were in place to ensure the premises were maintained. Health and safety audits were completed. There was a business continuity plan in place which was monitored and reviewed. We observed inspecting on-site that the building had been purpose-built. Doorways were wheelchair accessible; there was a lift available and toilets were disability friendly with pull cords and grab rails. However, we found, a small number of staff were not up to date with their health and safety training.

There were a range of clinical and non-clinical roles within the practice. Overall, staff training was not up to date, and the learning needs and development of staff were not always managed appropriately. A process was in place for the clinical supervision of consultations undertaken by locum GPs. There were formal appraisals for staff but some staff including nurses had never received one. The provider told us they recognised this was an area for development and was planning to commence in 2025. Safe recruitment practices were followed. Staff recruitment files contained relevant recruitment evidence.

Systems and processes for infection control were satisfactory. We found that there were effective processes in place for the oversight of infection prevention and control management. Annual audits were completed along with monthly handwashing competencies for staff. There was a clear policy for infection prevention and control. We saw evidence of Personal Protective Equipment (PPE) competencies. This was in line with NHS England National Infection Prevention and Control Guidelines (2022). However, the training matrix we reviewed, identified that 6 out of 54 staff had not completed infection prevention and control training level 1. This was not in line with NHS England National Infection Prevention and Control Guidelines (2022).

The service did not ensure that medicines and treatments were safe and met people’s needs, capacities, and preferences. Protocols for staff to follow to ensure they prescribed all medicines to service users safely, and ensured people received all recommended medicines reviews and monitoring were not robust enough. 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. There were no controlled drugs held on site. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments. There were oxygen signs on the doors used for storage. The provider had effective systems to manage and respond to safety alerts and medicine recalls. However, we identified through our clinical searches that 223 people who had been prescribed 10 or more medicines had not received a medicine review in the past 12 months. A random sample of 5 records identified there was no up-to-date medicine review, the oldest being dated 2021. We told the provider to provide an action plan to review these records. This was provided to us following our inspection. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.