Church Street 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.

We rated this key question 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 practice had a good learning culture, and processes were in place to support staff to report incidents, near misses and safety events. Managers investigated incidents thoroughly. Learning from incidents and complaints was discussed in meetings and resulted in changes that improved the service.

Leaders were committed to learning, and we discussed some examples of significant events and the actions the practice had taken in response to the learning identified. One incident involved related to Electrocardiogram (ECG) tests. An ECG is a test that records the electrical activity of the heart, including the rate and rhythm. Learning from this incident was to ensure Health Care Assistants (HCA’s) show the results of all ECG tests to the Duty GP before a patient leaves the premises to make sure any abnormalities are acted on appropriately and expediently.

The practice worked with patients and healthcare partners to establish and maintain safe systems of care. Staff worked to facilitate continuity of care, including when patients moved between services. There were protocols in place for managing incoming correspondence into the patient’s medical records.

Patient referrals to specialist services were documented in the referrals systems and patient record. The Wyre Forest Health Partnership had a ‘Quality, Performance and Risk Committee’ in place and as part of that remit, referral rates were actively monitored for all of their practices.

We found patient referrals were managed in a timely manner including 2- week wait referrals. A 2-week wait referral is an urgent NHS pathway where a patient is referred to see a hospital consultant within 14 days for symptoms that indicate cancer.

Safeguarding policies and procedures were in place to keep people safe and safeguarded from abuse. The practice had a nominated GP safeguarding lead, a Safeguarding Administrator, and a Safeguarding General Practice Assistant. Staff had completed the relevant safeguarding training for their role and shared concerns quickly and appropriately. We saw safeguarding posters located in various places around the practice to promote safeguarding and clarify the systems in place.

The practice maintained a list of vulnerable adults and children and acted on concerns working in partnership with other organisations. Clinical system alerts were used to identify people who were at risk of harm or abuse including household contacts. There were systems in place to respond to concerns and act on correspondence. For example, they followed up children who failed to attend their appointments or were frequent attenders to the accident and emergency department.

Safeguarding was discussed regularly at safeguarding meetings held every 6 weeks. The GP Safeguarding lead told us a specialist midwife joined the safeguarding meetings to discuss vulnerable patients. All staff were encouraged to ask any questions about safeguarding at practice meetings and were invited to attend safeguarding practice meetings for learning and education.

Staff could recognise a deteriorating patient and knew what action to take. Staff had received sepsis and basic life support training. There were processes in place to ensure care was prioritised for the most clinically vulnerable patients. We saw evidence of a ‘Red Flag’ sheet which provided information for the reception team on symptoms of sepsis, stroke, chest pain and meningitis.

Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

Emergency equipment was available and maintained. Systems were in place to check the emergency equipment and medicines regularly.

The practice facilities were fully accessible to patients. Consultation rooms were available on the ground floor and lifts provided access to the first floor for two additional consulting rooms.

The practice detected and controlled potential risks. They made sure equipment, facilities and technology supported the delivery of safe care. Contracts were in place to ensure the premises were maintained. Systems were in place for the checks of fire alarms, fire extinguishers and fire evacuation procedures. Portable appliance testing was completed annually to ensure equipment was safe to use. The practice provided us with evidence of health and safety risk assessments which showed that risks were properly managed.

There was a business continuity plan in place which was monitored and reviewed. As part of the Wyre Forest Health Partnership, Church Street Surgery had access to the various practice sites and could receive assistance from colleagues from across these sites, which enhanced their business continuity preparedness.

The practice made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. Leaders were supportive of staff developing their skills and there was an apprenticeship programme in place.

There were a range of clinical and non-clinical roles within the practice. GPs had also been nominated to lead on clinical areas such as drug and alcohol addictions; LGBTQ+; women’s health; and diabetes.

We found learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence. We saw examples of staff who had been encouraged to develop their careers. For example, one staff member who was a phlebotomist had been supported to train as a Health Care Assistant; and the Site Manager had progressed to the role from a receptionist.

Leaders explained they had mentoring and supervision systems in place for clinical staff. For example, GPs were assigned a ‘buddy’ and the Wyre Forest Health Partnership arranged ‘GP Buddy’ days for staff. Dedicated time was allocated for supervision sessions for clinical staff. Leaders told us they had an ‘open door’ culture for all staff and encouraged staff to meet for coffee breaks. This facilitated good communication between clinical staff for advice and support.

In addition, for clinicians who are prescribers, prescribing tutorials were arranged and a sample of prescriptions were reviewed to determine if prescribing was in line with local and national guidance.

On an annual basis the Wyre Forest Health Partnership arranged away days for clinical staff for teaching sessions.

As part of our assessment, we reviewed staff personnel files and training records. We found safe recruitment practices were followed and appropriate checks had been completed. In addition, staff had completed necessary training according to their roles within the practice.

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 an infection control policy in place and a designated infection, prevention and control (IPC) lead. Staff had completed relevant infection control training. Risk assessments and audits were completed, and actions taken to mitigate risks. Clinical waste procedures were in place. The practice had effective oversight of the external cleaning company to ensure cleaning schedules were followed and cleanliness met the required standard.

The practice strived to make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved patients in planning, including when changes happened.

Staff involved patients in reviews of their medicines and helped them understand how to manage their medicines safely. Patients knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms.

Medicines were stored securely and at appropriate temperatures. Refrigerators used to store vaccines and medicines were monitored to ensure temperatures were maintained and products were appropriately stored within them. Staff regularly checked stock levels and expiry dates for all medicines, including emergency medicines. There were Patient Group Directions (written instruction to help specific healthcare professionals supply or administer medicines to patients)in place which relevant staff worked to.

There was a programme of regular clinical audits of prescribing that focused on improving care and treatment. We discussed with staff an audit which had been undertaken on asthma and the overuse of Short-acting beta-2 agonist (SABA) inhalers. Actions taken by clinicians to reduce patient overuse of SABA inhalers were reflected in the results of the audit which demonstrated that overuse had has reduced from 1.5% to 0.95% of adult asthma patients. In addition, 90% of these patients had received an asthma review within the last 12 months, which was an improvement of 45% of patients previously.

Prescribing data was reviewed as part of our assessment found practice performance was in line with national averages for Pregabalin and Gabapentin medicines (primarily anticonvulsant drugs, also prescribed for pain); and antibiotics. The practice performance for the prescribing of multiple psychotropic medicines (used to treat various mental health conditions) was slightly above the national average.

As part of our assessment a Care Quality Commission GP Specialist Advisor undertook searches of patient records on the practice’s clinical system. Our clinical records review identified the following:

Methotrexate (a drug used to treat rheumatoid arthritis): We identified 59 patients prescribed this medicine and found no issues with the monitoring being provided for them.

Aldosterone antagonist (a drug used to treat heart failure, resistant high blood pressure, and certain cases of excess fluid retention): We identified 87 patients prescribed this medicine and found no issues with the monitoring being provided for them.

Bisphosphonate (medicines that strengthen bones): National guidance recommends that after a patient has been taking this oral medicine for 5 years, the need for continuing treatment should be reassessed and consideration should be given to providing a Dual‑Energy X‑ray Absorptiometry (DEXA) scan. DEXA scanning offers a non‑invasive and highly accurate method for evaluating body composition, including bone mineral density. We identified 71 patients who had been prescribed this medicine for over 5 years. We reviewed in detail the records of 5 patients and found no issues with the treatment and monitoring of these patients.

Safety Alerts: There was a process in place for recording and sharing medicine safety alerts. Safety alerts were discussed in clinical meetings. We reviewed patients who were prescribed Sodium-glucose co-transporter-2 (SGLT-2) Inhibitors (drugs used to treat type 2 diabetes, heart failure, and chronic kidney disease). SGLT-2 inhibitors are linked to a rare but serious risk of Fournier's gangrene. We identified a total of 509 patients prescribed these medicines. We looked in detail at 5 of these patient records and found evidence all 5 patients had been given information on the risks of taking this medicine.

Medication reviews: We reviewed a random sample of 5 medication reviews out of a total of 1959 reviews that had been completed for patients in the previous 3 months. We found no issues with any of these medication reviews and found they had been appropriately coded and contained necessary information.