Hagley 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.

At our last assessment, we rated this key question as Good. At this assessment, the rating remains the same.

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 practice had processes for staff to report incidents, near misses and safety events. The practice had a positive culture of safety and leaders encouraged staff to raise concerns when things went wrong. Staff felt there was an open culture, and that safety was a top priority. Patient feedback we received indicated that patients felt supported to raise any concerns with staff.

Lessons were learnt to continually identify and embed good practice. 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 incorrect stool sample test kits being given out by staff to patients. A new poster guide was provided for reception staff relating to sample kits and staff were also provided with training in this area. A second incident related to a teenage patient who was booked for an appointment for a Human papillomavirus (HPV) vaccine. As the practice had no records of previous vaccines and it appeared the patient had not had their childhood vaccinations; staff decided to provide the vaccinations. After the appointment, the patient’s records were received, and it was found that the patient had previously received their childhood vaccinations. The learning outcome for this incident was for Nurses to contact the Child Health Information Service (CHIS) directly to confirm patient vaccination status.

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. We found referrals were managed in a timely manner.

Safeguarding policies and procedures were in place to keep people safe and safeguarded from abuse. The practice had a nominated GP safeguarding GP lead and a Safeguarding Administrator. Staff had completed the relevant safeguarding training for their role and shared concerns quickly and appropriately. 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.

Quarterly safeguarding meetings with the practice safeguarding leads and multidisciplinary healthcare professionals took place where safeguarding risks and patient care was discussed.

Staff could recognise a deteriorating patient and knew what action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated. There were processes in place to ensure care was prioritised for the most clinically vulnerable patients.

As part of our assessment, we checked the emergency equipment and medicines available and the reviewed the processes to maintain these. We found adrenaline medicine (used in emergencies to treat severe allergic reactions, cardiac arrest, and severe asthma attacks) was not located within all of the consultation rooms where vaccines were administered to patients. This was not in line with the Resuscitation Council UK recommendations. Emergency medicines were located in a locked cupboard in a locked room in the practice. Emergency medicines should be readily accessible in an emergency.

Emergency medicines, except for those subject to additional storage requirements, should notbe stored within locked cupboards or rooms as this can cause an unacceptable delay in the event of an emergency. In addition, we found there was no signage to indicate the location of emergency drugs, oxygen or the Automated External Defibrillator(AED). We raised these concerns with leaders who took immediate action to address these issues.

The practice facilities were fully accessible to patients. The building was step-free for patients, with full access for wheelchair users. Consultation rooms were located on the ground floor.

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. Staff explained that being part of the Wyre Forest Health Partnership meant they had access to the various practice sites and could receive assistance from colleagues which enhanced their business continuity preparedness. For example, staff told us that in response to a recent IT outage, the Wyre Forest Health Partnership had implemented an Operations Lead rota to co-ordinate all practices within the partnership.

The practice made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development.

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.

We discussed clinical supervision of the Physicians’ Assistant and leaders explained the Site Lead GP acted a mentor for this staff member, providing supervision and de-brief sessions where patient care was discussed. Clinicians also met daily at coffee breaks.

Leaders told us they operated an open-door policy for Advance Nurse Practitioners to access support from GPs and discuss any patient cases they wanted guidance with.

Clinical meetings were held and monthly tutorial supervision meetings were provided. Half-day teaching sessions were also provided regularly for Advanced Nurse Practitioners. On a quarterly basis a prescribing audit was undertaken to provide assurance of appropriate clinical care.

As part of our assessment, we reviewed staff personnel files and training records. At the time of our onsite visit, we identified gaps in the records of some staff members, however following our visit we were provided with evidence of the missing documentation.

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. We saw evidence of infection control risk assessments including Legionella (a term for a particular bacterium which can contaminate water systems in buildings). Infection control audits were routinely completed and actions taken to mitigate risks. Practice cleaning schedules were in place for the external cleaning company commissioned.

As part of our assessment, we reviewed the clinical waste procedures at the practice. We identified used sharps boxes were located in a communal patient area of the practice; and the outside clinical waste bin was not locked. We raised these concerns with leaders who took immediate action to address these issues. Leaders instructed staff to ensure they disposed of the sharps boxes themselves and not leave them in a communal area, and the cleaners were informed of this. Staff and cleaners were also instructed to ensure the outside clinical waste bin is locked after each use.

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 instructions 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. This included audits on gestational diabetes (high blood sugar which develops during pregnancy), hypertension (high blood pressure), and hormone replacement therapy (drugs used to treat the menopause).

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); psychotropic medicines (used to treat various mental health conditions); and antibiotics.

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 (an immune system suppressant drug): We identified 46 patients prescribed this medicine in the last 6 months and found all patients had received the required monitoring and were appropriately coded on the clinical system.

Angiotensin-converting-enzyme (ACE) Inhibitors (a drug used primarily for the treatment of high blood pressure and heart failure): We identified 1135 patients prescribed this medicine and reviewed in detail the clinical records of 5 patients. We found 4 out of the 5 patients had received the required monitoring and the 1 patient who was overdue for monitoring had been booked for an appointment. All 5 patients were coded appropriately on the clinical system.

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 50 patients who had been prescribed this medicine for over 5 years and reviewed the records of 5 patients. We found 4 patients had received a DEXA scan and 1 patient was no longer being prescribed this medicine.

Safety Alerts: There was a process in place for recording and sharing medicine safety alerts. Safety alerts were discussed in clinical meetings. Our review of clinical records indicated that safety alerts were actioned in line with guidance. For example, we reviewed patients who were prescribed both an Aldosterone antagonist (a diuretic medicine which prevents potassium loss) and an ACE inhibitor. We found these patients had received appropriate urea and electrolyte blood test monitoring in accordance with national Medicines and Healthcare products Regulatory Agency (MHRA) drug safety alert guidance.

Medication reviews: We reviewed a random sample of 5 medication reviews out of a total of 921 reviews that had been completed for patients in the previous 3 months. We found the medication reviews had been appropriately undertaken for all of these patients.

As part of our assessment, we reviewed the processes in place for controlled drugs. Controlled drugs are medicines that are regulated by the government. This is usually because they are at higher risk of causing harm (such as dependence or misuse). There was a controlled drugs policy in place however we identified this was not being followed in relation to the checking of drugs being carried out by two people. Leaders took immediate action to address this issue and instructed staff to ensure countersignature of checks undertaken. In addition, the practice arranged for the Clinical Pharmacist to undertake regular audits of controlled drugs.