Broad Street Health 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.

The practice had a good learning culture and people could raise concerns. Managers investigated incidents thoroughly. People were protected and kept safe. Staff understood and managed risks. The facilities and equipment met the needs of people, were clean and well-maintained and any risks mitigated. There were enough staff with the right skills, qualifications and experience. Managers made sure staff received training and regular appraisals to maintain high-quality care. Staff managed medicines well and involved people in planning any changes.

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.

Staff were encouraged to raise concerns when things went wrong. We saw the practice investigated incidents and complaints and these were documented. The ones we reviewed had detailed analysis and outcomes. There was a system to share any learning with staff, and we saw evidence were learning from incidents and complaints resulted in changes that improved care for others.

The practice 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.

Regular multi-disciplinary team (MDT) meetings were held at the practice and at the primary care network (PCN) level to review the care of patients with complex conditions or those nearing the end of their lives, ensuring holistic, well-coordinated care was in place.The provider managed referrals to secondary care, including urgent referrals for suspected cancer, and followed these up appropriately. The cancer detection rate observed at the practice was higher than the local and national averages. Communications from secondary care services, such as discharge summaries and test results were processed efficiently to ensure continuity of care.

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 service shared concerns quickly and appropriately.

The service had a designated lead for safeguarding adults and children at risk and staff were aware of who they were. The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations. The minutes from the monthly clinical governance meetings showed any patients assessed as at risk were discussed and reviewed. We noted that safeguarding alerts were added to the clinical records when relevant, ensuring that all staff were aware of ongoing concerns and could act accordingly. Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures.

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

The practice ensured that the equipment, facilities, and technology were well maintained and supported the safe delivery of care. All clinical equipment had up to date calibration and Portable Appliance Testing (PAT) was in place. Based on patient feedback, the practice installed clear and visible signage throughout the building to assist overall accessibility and safety.

Fire safety procedures were actively managed including, emergency light and fire alarm checks and regular checks conducted by external contractors in partnership with NHS property services. Legionella testing was managed with certification available to ensure water systems were monitored and safe.

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

The practice ensured that the equipment, facilities, and technology were well maintained and supported the safe delivery of care. All clinical equipment had up to date calibration and Portable Appliance Testing (PAT) was in place. Based on patient feedback, the practice installed clear and visible signage throughout the building to assist overall accessibility and safety.

Fire safety procedures were actively managed including, emergency light and fire alarm checks and regular checks conducted by external contractors in partnership with NHS property services. Legionella testing was managed with certification available to ensure water systems were monitored and safe.

The practice made sure there were always enough qualified, skilled and experienced staff, who received thorough support, supervision and strong development opportunities. 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, and staff were working within their agreed areas of competence. The practice had developed competency frameworks for all their clinical and non-clinical staff enabling career progression and ensuring consistency in skills, training, and performance expectations.

The practice 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. Staff received regular training and were competency assessed on medicines optimisation.

We saw that the practice had developed a new process to manage prescription stationery appropriately and securely.

Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines. They stored medical gases, such as oxygen, safely and completed required safety risk assessments. The provider had effective systems to manage and respond to safety alerts and medicine recalls.

The practice took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. We noted that antibiotic prescribing for the practice was lower than the local and national averages.

Our review of the patient clinical record system showed that patients who were prescribed high risk medicines were being monitored effectively. However, a small number of patients were overdue checks relating to their medicines. The provider was responsive to our findings and addressed these immediately by developing a standard operating procedure to ensure timely and consistent practices.

The practice 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. Staff received regular training and were competency assessed on medicines optimisation.

We saw that the practice had developed a new process to manage prescription stationery appropriately and securely.

Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines. They stored medical gases, such as oxygen, safely and completed required safety risk assessments. The provider had effective systems to manage and respond to safety alerts and medicine recalls.

The practice took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. We noted that antibiotic prescribing for the practice was lower than the local and national averages.

Our review of the patient clinical record system showed that patients who were prescribed high risk medicines were being monitored effectively. However, a small number of patients were overdue checks relating to their medicines. The provider was responsive to our findings and addressed these immediately by developing a standard operating procedure to ensure timely and consistent practices.