Halcyon 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 assessed all 8 quality statements under the safe key question. We looked for evidence that people were protected from abuse and avoidable harm. This is the first inspection for this practice since its registration with CQC. Our rating for this key question is good.

We found that safety was a priority for everyone. People were protected from abuse and avoidable harm. There was a transparent, no-blame culture that encouraged staff and people to speak up when things went wrong. When people raised concerns about safety there was learning to ensure continuous improvement. Services were planned and organised with people at the centre to ensure safe transitions between care settings. People were supported to understand care information enabling them to make positive choices about their healthcare that minimised the risk of harm. Leaders ensured there were enough skilled staff to deliver safe care. Mostly,there were governance arrangements that protected staff and people from risk of harm including effective infection prevention and control procedures. The practice used a range of searches on the clinical system regularly and had safeguards in place to ensure that people received reviews of their medicines, long-term conditions or monitoring in line with national guidance. Medicines and blank prescription stationery was stored, used and disposed of safely.

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 practice 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 we spoke with when we visited the site had not needed to complain but felt they would be supported to do so and their concerns would be investigated if they did. Evidence we saw showed that the practice took concerns seriously and improved as a response.

There were only 9 reported incidents that provided an opportunity for learning in the last 12 months. This could have indicated under reporting by staff. When we asked managers about this, they immediately raised reporting of this type of events in their daily staff meeting (the huddle) and encouraged staff to speak up when things went wrong. Staff told us that during weekly clinical meetings, the whole team discussed and learnt from clinical incidents.

Staff felt strongly there was an open culture, and that safety was a top priority. The practice had processes for staff to report incidents, near misses and safety events which all staff understood and knew how to use. There was a system to record and investigate written complaints, when things went wrong, we saw that staff apologised and gave people support. Complaints and learning events were a standing agenda item for the daily huddle and verbal complaints were raised and discussed within 24 hours at this meeting. The leadership team reviewed complaints and learning events annually to see if there were trends that needed further action or investigation. The practice has registered with the Learning from Patient Safety Events service which is a national NHS system for the recording and analysis of patient safety events that occur in healthcare. Learning from incidents and complaints resulted in changes that improved care.

The practice always worked with people and healthcare partners to design, establish and maintain safe systems of care. There was always continuity of care, including when people moved between different services. For example, when vulnerable people moved to a new practice, staff wrote a personalised letter to ensure that all important information was passed on.

People’s feedback was mixed. Some reviews on the Healthwatch and NHS websites mentioned difficulties registering with the practice. People we spoke to during our site visit did not report any problems with being referred to other services. We saw one person being supported by staff to use the QR code to access registration forms. The practice had recently commissioned an external company to process new registrations. A dedicated staff member managed deductions from their practice list as the transient nature of their population meant there was a high turnover of people. This ensured people who no longer lived in the practice area were not at risk.

The practice had robust systems for managing referrals and all rejected or delayed referrals were monitored. We saw that all urgent 2 week wait referrals were followed up to ensure that the patient had received an appointment. Letters and test results were managed effectively and efficiently, we did not identify any delays in managing information. Locum and trainee doctors were provided with a handbook to ensure they understood local referral procedures and all associated policies. When GP’s requested Advice and Guidance from secondary care colleagues (specialists or consultants) a dedicated administrator monitored responses on a weekly basis.

Staff told us that they worked with other providers to deliver shared care for example, a dedicated pharmacist managed all shared care agreements for transgender and neurodiverse people. Leaders had identified there were long delays referring people locally for adult ADHD and autism assessments. They actively sought out alternative NHS providers and explained to people that they could be referred to these providers under the “Right to Choose” pathway (this gives people a legal right to choose their mental healthcare provider). As a result, waiting times for assessments had improved significantly from 18 months to 6 weeks. In order to maintain patient safety, all staff carried out a 3 point identity check at the start of each consultation.

The practice 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 practice shared concerns quickly and appropriately. There was an experienced, engaged and capable safeguarding lead supported by a deputy, and 2 specific safeguarding administrative leads. Safeguarding policies were in place, comprehensive, up-to-date and regularly reviewed. All staff understood their responsibilities around safeguarding and were appropriately trained in safeguarding procedures.

A random sample of staff files we reviewed showed all staff had suitable Disclosure and Barring Service (DBS) checks based on the role and responsibilities of the job and had completed adult and child safeguarding training with the recommended frequency. The DBS checks whether a prospective employee has a criminal record or has been barred from working with children or vulnerable adults, depending on the level of check carried out.

The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations. This list is accessible to all staff on the practice’s electronic notepad and is colour coded to indicate level of risk. This enables staff (including administrative staff booking appointments) to quickly recognise vulnerable patients and offer appropriate support. Regular safeguarding meetings were held with the local multidisciplinary team such as health visitors. Staff were aware of safeguarding issues specific to their practice population. Appropriate clinical coding was used to flag people on the safeguarding register and their family members. Staff, including non-clinical staff were able to describe instances where they had identified safeguarding concerns and the practice safeguarding team had taken action to protect people from abuse and neglect. The practice is part of the accredited Identification and Referral to Improve Safety (IRIS) programme, this is a specialist domestic violence and abuse training, support and referral programme for general practices.

The practice 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. In the 2024 national GP patient survey, 96% of people who responded said they were involved as much as they wanted to be in decisions about their care and treatment. This was above the national average of 91%. People we spoke to said they had been signposted to appropriate support by their doctor and had been given suitable advice on how to manage changes in their condition.

All administrative and reception staff were trained in care navigation and were able to appropriately signpost people to services such as Pharmacy First. Pharmacy First is a government scheme which allows qualified pharmacists to prescribe medicines for 7 specific minor illnesses. All staff could recognise a deteriorating patient and explain how they identified people who might be experiencing a medical emergency such as sepsis and how they would manage that person. There was always a duty GP available if they needed urgent advice. Emergency equipment and medications were available and well-maintained.

Our records review indicated people with long term conditions received reviews that were thorough and people were given safety-netting advice to deal with risks that may occur. We reviewed a random sample of Do Not Attempt Cardiopulmonary Resuscitation (DNA CPR) forms. We saw that staff had sensitive conversations with people and their families about their needs and preferences. Staff followed suitable processes to assess people’s mental capacity and to obtain informed consent.

The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. The practice leased the building but had invested in it, refurbishing the fire exits, replacing the lift and converting 3 storage rooms into clinical rooms.

We saw a range of risk assessments which were monitored relating to fire, health and safety and general maintenance. The building was modern and well-maintained. The building had 1 lift to access the entire practice. Staff told us if the lift failed, they would contact people with mobility needs to cancel their appointments and rebook them. Urgent appointments would be converted to either a telephone call or a home visit depending on the person’s needs. However, on-line feedback from the Healthwatch website viewed by the CQC suggested that this was not always possible.

There was a unisex accessible toilet, unisex baby changing facilities and a private room in reception which could be used by breast feeding parents. Clinic rooms were clean and well-equipped. Some rooms had fixed height couches which can present a health and safety risk, however there were motorised couches available and this had been risk assessed.

On the day of our visit, we found there was no hot water in some clinic rooms. Leaders were aware that there were some ongoing problems with the hot water system but were not aware of any issues on the day of the visit. The water heating system and taps had been tested as part of the annual Legionella risk assessment on 16 January 2025. Legionella is a bacterium that can grow within the water systems of buildings. The risk assessment showed the water from all hot taps was reaching the required safe temperatures to prevent Legionella growth. Since our initial site visit further work has been undertaken and the problem resolved. A range of suitable audits and spot checks were undertaken to maintain the cleanliness of the building. However, a monthly audit of water temperatures did not show that staff took action when the hot water did not reach the required temperature.

We saw that all portable electrical equipment had been regularly tested and all clinical equipment had been calibrated and serviced. There was appropriate firefighting equipment, an evacuation policy, regular fire drills and fire alarm tests. There was a business continuity plan in place.

The practice made sure there were enough qualified, skilled and experienced staff, who worked together well to provide safe care that met people’s individual needs. CQC had received information that the practice overly relied on GP trainees and partners were infrequently on site, however evidence we saw did not support this. We reviewed appointment data for the last 4 months and found there was always at least 1 salaried GP and 1 partner on site every day. The average number of patients per fully qualified full-time equivalent GP in England is 2,328, this practice has 1 GP for every 2,125 patients. Staff we spoke with told us that GP trainees only provided clinics in addition to salaried GPs and partners.

There was a duty doctor daily who had no clinic but was available for advice, clinical supervision, to review urgent test results and see people who needed an urgent appointment as required. Salaried GPs told us this system allowed them to provide timely clinical supervision and advice to other clinical and administrative staff. The practice had 3 non-medical prescribers and had processes in place to monitor and audit their clinical practice quarterly. Leaders had recently increased staffing by recruiting salaried GPs and other clinical roles such as a First Contact Physiotherapist.

A sample of staff files we reviewed showed that all staff were suitably qualified, maintained their professional registrations and their continuing professional development (CPD) and had up-to-date specialist training appropriate to their role. All staff had appraisals, access to regular clinical supervision and protected time to complete their mandatory training. Supervisors ensured all staff completed their mandatory training and induction checklist before starting in their role. Safe recruitment practices were followed. In the 2024 national GP patient survey 96% of people said they had trust and confidence in their healthcare professional; this is above the national average of 92%.The practice provided home visits for patients meeting certain criteria. To ensure the safety of staff visiting patient homes 2 staff were allocated to each visit, a risk assessment was completed and the practice provided taxi transport.

The practice 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 had relevant training at a level suitable for their role. The practice had invited the IPC lead at the Integrated Care Board (ICB) to undertake a joint initial audit when the current provider took over the practice, to establish the correct format for the audit and baseline requirements and actions. The IPC lead at the practice then completed an annual audit after this. A hand hygiene audit of staff handwashing was done quarterly. IPC information was displayed in all clinic rooms for example handwashing guidance placed by the sink. We saw that actions were taken as a result of audits to mitigate risks.

CQC had received some information regarding a lack of cleaning schedules at the practice, however, we did not find any evidence to support this. People’s feedback was positive about hygiene and cleanliness. We found the premises to be clean, suitable cleaning products were available and staff cleaned their clinical room and equipment at the end of each clinic. Cleaning schedules were in place and followed and the IPC lead had regular communication with the cleaning team. There were up-to-date appropriate policies for the management of IPC, including waste and cold chain management, which all staff could access. Antimicrobial stewardship was maintained by staff following national and local guidelines and antibiotic prescribing was audited by the ICB quarterly.

We found some issues with the hot water supply. On the day of our visit, there was no hot water in some clinic rooms. This was an infection control risk; however, alcohol hand gel was available in all the clinic rooms so staff could clean their hands appropriately. Gloves were also available. The lack of hot water did not affect every clinic room on the day of our visit, staff could use a different clinic room as there were rooms available or use a sink in a different clinic room if their hands were visibly dirty (IPC guidance on handwashing states this is when washing hands with soap and water is required and alcohol hand gel is not a suitable alternative). Since our assessment, the practice has identified and resolved the cause of the problem.

The practice always made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff at the practice involved people in medicine reviews and helped them understand how to manage their medicines safely. People knew what to do if their condition did not improve or they had any unexpected symptoms.

All prescribers were audited quarterly and received feedback. All staff felt confident managing the storage, administration and recording of medicines. Staff managed prescription stationery appropriately and securely. Staff followed protocols to ensure they prescribed all medicines safely, and ensured people received all recommended medicines reviews and monitoring. 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. The practice had effective systems to manage and respond to safety alerts and medicine recalls. Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring.

Remote clinical searches carried out by CQC found no concerns with monitoring of people on high-risk drugs. Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. For example, the practice was performing better than the ICB average in an ICB audit from 7/7/23 - 8/11/24 of gabapentinoid and opioid prescribing. The practice had reduced the number of people prescribed these medicines and increased the number of people with a documented pain management plan. We saw that the total number of antimicrobial prescriptions issued by the practice between January and December 2024 was significantly lower than local and national averages. We saw an extensive programme of clinical prescribing audits comprising 8 medication audits in the last 12 months. People we spoke to found it easy to request repeat medication prescriptions.