Archived: Abbey 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 looked for evidence that people were protected from abuse and avoidable harm.

The practice had a good learning culture and people could raise concerns. Managers investigated incidents thoroughly. People were protected and kept safe. 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. We saw evidence that all staff received training and regular appraisals to maintain high-quality care.

This is the first inspection for this service since its registration with CQC. This key question has been rated 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 service had a proactive and positive culture of safety, based on openness and honesty. Lessons were learnt to continually identify and embed good practice. We noted that managers fostered a culture where staff were encouraged to speak up when things went wrong and all staff were aware of the process to report incidents, misses and safety events. The members from the Patient Participation Group (PPG) felt the provider took concerns seriously and proactively made improvements to the service.

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. For example, there was a documented process and standard operating procedure in place for handling pathology results. The process had a summarising policy for processing information relating to new patients. At the time of the inspection, the practice had about 50 new patient notes that needed summarising. We saw evidence that referrals and test results were managed in a timely way.

One of the GP partners was the safeguarding lead for adults and children and held a safeguarding register. Safeguarding policies were in place and staff were appropriately trained in safeguarding procedures. The service maintained a list of vulnerable people and acted on concerns working in partnership with other organisations. Our review of clinical records showed patients had been appropriately coded where safeguarding concerns had been identified.Safeguarding meetings were held regularly to review people at risk and information was shared appropriately with external agencies. The practice has recently completed a safeguarding audit which found robust procedures and policies were in place for the effective management of safeguarding matters.

Staff were aware of the actions to take if they encountered a deteriorating or acutely unwell person. We noted that patients were advised on risks related to their condition and actions to take if their condition deteriorated. Staff were trained on basic life support and had completed sepsis training, which were part of the practice’s mandatory training requirements.

Emergency equipment was available and maintained. At the time of the inspection, the practice had the resuscitation equipment stored in a locked room which was accessible to all members of staff. However, the management were in the process of reviewing the suitability of this location to ensure it more readily available in the event of an emergency

The practice made sure equipment, facilities and technology supported the delivery of safe care. The facilities and premises were appropriate to meet the safe care and needs of patients. We saw that health and safety risk assessments had been completed in all areas such as legionella, fire and premises risk assessments were in place. The practice had safety policies, which were regularly reviewed and communicated to all staff.

Training records indicated that staff had received training related to fire safety. However, the practice had only one named fire marshal who had completed the required training.

There was a comprehensive business continuity plan in place, detailing procedures to be followed in the event of major emergencies.

We saw that systems were in place to check, maintain and calibrate equipment used to support patient care and treatment at the practice. Equipment was checked annually to ensure it was safe to use. The last checks were completed on the November 2024.

The service made sure there were always enough qualified, skilled and experienced staff, who received thorough support, supervision and strong development opportunities. The teams worked together well to provide safe care that met people’s individual needs. The average number of patients per fully qualified, full-time equivalent, GP in England was 2,328, which meant the practice had 1 GP for every 2,125 patients. We found training was up to date and learning needs and development of staff was managed appropriately.

There were procedures in place for the safe recruitment of staff. On reviewing a random sample of staff files, we identified there were no gaps in the recruitment processes.
Our review found there were processes in place for staff appraisals and regular clinical supervision. Staff feedback confirmed they were able to share concerns without fear of retribution.

The practice has implemented competency frameworks for all staff working at the practice which supported staff development and oversight.

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.

At our onsite inspection of the practice, we observed the premises to be visibly clean and tidy. Cleaning schedules were in place for the practice cleaner and other staff to follow. The schedule included checks and audits of the standard of cleaning carried out.

The practice worked with the clinical pharmacists from the local primary care network to monitor prescribing and management of patients on high-risk medicines and other medicines which required monitoring. We carried out remote searches of clinical records as part of our inspection. These included a review of records for patients prescribed high risk medicines to ensure that records were accurate and contained up to date reviews and monitoring. We found that in most cases the patients received appropriate reviews and monitoring.

The practice had process in place to manage prescription stationery appropriately and securely.

Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines, vaccines, and controlled drugs. They stored medical gases, such as oxygen, safely and completed required safety risk assessments. The provider had effective system to manage and respond to safety alerts and medicine recalls. Prescribing data reviewed as part of our assessment confirmed this.

We found Patient Group Directions and Patient Specific Direction (written instructions to supply or administer medicines to patients without a prescription or an instruction from a prescriber) were in good order.