BHF Highgate 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

The service had a good learning culture and people could raise concerns. Managers investigated incidents and complaints thoroughly. People were protected and kept safe although the provider was not following their own safeguarding policy with regard to staff training levels and frequency. 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. The service made sure that medicines and treatments were mostly safe and met people’s needs, capacities and preferences. However, there were some areas of medicines optimisation that required review.

This service scored 69 (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 had a process in place for staff to report serious incidents which were acted upon and changes and learning discussed with staff at team meetings. However, they did not report near misses or general safety events. Leaders told us they would look to incorporate these into their incident reporting moving forward to drive improvement and change. There was a system to record and investigate complaints including informal complaints. We saw all complaints were investigated, actions taken and a comprehensive response sent to the complainant with details on how to escalate their concerns if they were not happy with the practice’s response. When things went wrong, staff apologised and gave people support. We saw notes from meetings where complaints and serious incidents had been discussed with staff. Learning from serious incidents and complaints resulted in changes that improved care for others. For example, staff had discussed and reviewed the process of checking patients’ medication against their most recent hospital discharge letter during registration with the practice.

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. There were systems in place for processing information relating to new patients. Referrals and test results were managed in a timely way. Systems were in place to prioritise and monitor urgent referrals.

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 whilst protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. Safeguarding policies were in place and known to staff, who were trained in safeguarding procedures. However, the training frequency of staff and the level of training for non-clinical staff, although met national guidance, did not align with their own safeguarding policy. The provider updated their training programme to reflect their safeguarding policy immediately following the assessment and confirmed all non-clinical staff would receive training to the level stipulated in their policy within 4 weeks. The service shared concerns quickly and appropriately. The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations.

The service worked with people to understand and manage risks. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Emergency equipment was available and maintained. Staff could recognise a deteriorating patient and knew what action to take. From the records we reviewed we saw patients were advised on actions to take if their condition deteriorated.

The service was fully aware of all potential risks in the care environment and controlled them very effectively. They made sure equipment, facilities and technology supported the delivery of safe care. Contracts were in place, where appropriate, to ensure the premises were maintained. Comprehensive health and safety risk assessments and audits had been undertaken and risks identified had been addressed promptly. All safety checks were recorded and there was good oversight and monitoring of these. 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. Learning needs, development, staff competencies and clinical supervision were managed appropriately. Staff newly recruited had received an induction including locum GP staff. We reviewed staff training records and found staff had received and were up to date with mandatory training and all were mostly up to date with other training identified on the schedule. Where staff were overdue, we saw evidence leaders had addressed this with automated email reminders and discussions. Following the assessment the training schedule had been updated to reflect the frequency and level of safeguarding children training stipulated in their safeguarding policy. The provider had appropriate recruitment processes in place. We reviewed 3 personnel files and found safe recruitment practices had been followed including disclosure and barring service (DBS) checks.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and knew how to share concerns with appropriate agencies. The practice had a designated infection, prevention and control (IPC) lead and staff had received relevant induction and training. Cleaning schedules were in place and followed and all areas of the premises were clean and tidy. An annual IPC audit had been completed, and we observed actions had been taken to mitigate risks identified. For example, wall mounted soap dispensers had been put in place. We observed the disposable privacy curtains were changed every 2 years and the provider did not have a risk assessment in place for this rational. The provider confirmed the new Chief Nurse and Practice Senior had a meeting scheduled for 3 July 2025 to review this.

The service made sure that medicines and treatments were mostly safe and met people’s needs, capacities and preferences. However, there were some areas identified that required reviewing.

Not all relevant patients had received a recommended medicine review. We identified during our clinical searches that 70 of the 166 patients on polypharmacy (10 or more repeat medicines) and 64 of the 111 patients on a Gabapentoid medicine (medicines used to treat epilepsy and neuropathic pain) were overdue a medicine review. The provider confirmed a new Pharmacist had been appointed and had been allocated time to complete these as a priority.

Patient Group Directions (PGDs) are written instructions allowing non-prescribing health professionals to administer specified medicines to a specific group of patients without a specific prescription. These had been signed by the authoriser for staff deemed competent to administer these. However, some non-prescribing staff had signed these several months after the authoriser. The Practice Senior took immediate action to address this.

The provider had a policy and a system in place to manage and respond to safety alerts and medicine recalls although they did not have a monitoring overview of which safety alerts had been reviewed and what action had been taken. The provider implemented a monitoring recording log immediately following the assessment. We observed a recent medicine alert had been received and action taken.

Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring. Findings from clinical searches showed generally good oversight and monitoring of patients prescribed high risk medicines. However, we observed risk advice for patients on teratogenic drugs (medicine that when taken by a pregnant person, can interfere with the normal development of a foetus) was not clearly documented in their record. The provider carried out a review of all these patients immediately following the assessment and took appropriate action where required.

Staff managed prescription stationery appropriately and securely. Medicines were stored securely and at appropriate temperatures. We observed a recent temperature breach of a medical fridge had been handled in line with recommended guidance. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines. 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 broad-spectrum antimicrobials issued by the provider was lower than local and national averages. There was a programme of regular audits of prescribing that focused on improving care and treatment.