Umbrella Medical at Hatherton 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

The practice had a good learning culture and people could raise concerns.

Processes were in place to ensure learning was shared with all of the team to mitigate future risks. 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 mostly managed medicines well and involved people in planning any changes. We found a breach of Regulation 12 in relation to safe care and treatment. People on high-risk medicines and with long term conditions were not always being monitored appropriately. We have asked the provider for an action plan in response to the concerns found at this assessment.

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 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.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. Representatives from the Patient Representation Group (PRG) felt the provider took concerns seriously and proactively made improvements to the practice. Managers encouraged staff to raise concerns when things went wrong. During staff meetings, the whole team discussed and learnt from clinical issues. Staff felt there was an open culture.

The provider had processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Learning from incidents and complaints resulted in changes that improved care for others. All concerns were processed using a spreadsheet to ensure this was consistent, recorded and reviewed correctly. Patients were signposted to other organisations, should they wish to raise their concerns further.

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.

The practice had systems in place for processing information relating to new patients. The practice worked with other providers to deliver shared care and when patients moved between services. The practice worked closely with services to provide home visits, and they had a dedicated home visiting team. Referrals and test results were managed in a timely way. Staff responsible for summarising and processing new patient records confirmed that summarising was both up to date and completed in a timely manner.

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 practice shared concerns quickly and appropriately.

Following the onsite assessment, we saw adults who were on the safeguarding registers had alerts added to their notes. We saw that children on the safeguarding register were linked to family members.

Clinical and non-clinical leads monitored a range of registers, including mental health, cancer and learning disability registers, to ensure patients were booked for appropriate reviews.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations. The practice had two safeguarding leads one for adults and one as a paediatric lead who were dedicated to their role. Staff knew how to raise a safeguarding concern and who their safeguarding leads were.

The practice worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff were aware of how to recognise a deteriorating patient and knew of action to take if they encountered a deteriorating or acutely unwell patient. They had been given guidance on identifying such patients. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

All staff were trained in basic life support.

The practice mostly detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. However, following our onsite inspection we found oxygen bottles were not always appropriately managed. At the time of the inspection the practice had not shared a risk assessment with Care Quality Commission (CQC).

Health and safety related assessments and procedures to manage health and safety were in place. A range of health and safety risk assessments and fire risk assessments had been completed. Fire marshals had undertaken additional training for the role. Systems were in place for the regular checks of fire alarms, extinguishers and fire evacuation procedures with regular checks carried out around the building. The most recent fire drill had been completed this year. Regular monitoring was in place to ensure guidelines were adhered to and all staff had been made aware of the appropriate procedures to follow. 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.

Staff had been provided with training in health and safety related topics such as fire safety, infection control, basic life support and resuscitation training. Staff reported during discussions that they had no concerns regarding the arrangements in place to ensure health and safety.

The practice had completed assessments in place for the control of substances hazardous to health (COSHH). Evidence provided by the practice showed equipment was regularly calibrated and electrical items were PAT (portable appliance testing) tested. The latest calibration of equipment had been completed in December 2025.

During our site visit we found the premises were well maintained. The provider detected and controlled potential risks in the environment. They made sure equipment, facilities and technology supported the delivery of safe care. Regular checks were carried out on the premises, facilities and the equipment provided.

Contracts were in place to ensure the premises were clean and well maintained. Clear signage around the building supported people and staff in the event of an emergency evacuation on both floors.

The practice 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 health centre. We found training was up to date, learning needs and development of staff were managed appropriately and effectively, and staff were working within their agreed areas of competence. Safe recruitment practices were followed. There were no gaps in staff immunity history of the records we had checked on site.

Annual appraisals were completed for all staff, while individuals with enhanced roles received regular competency assessments and clinical supervision. Non-medical prescribers prescribing had oversight and were subject to regular audits and any knowledge gaps supported withadditionallearning and support.

Thepracticeassessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns withappropriate agenciespromptly.

Thepracticehad a designated infection, prevention and control lead and all staff had had relevant training. Cleaning schedules were in place and followedregularly. Risk assessments and audits were completed, and actions taken to mitigate risks.In general, we sawthe environment was visiblyverycleanand tidy in all areas includingdesks and chairsand equipment.

The practice mostly made sure that medicines and treatments were safe and met people’s needs, capacities and preferences but there were some gaps in medicines management.

Prescribing data reviewed as part of our assessment confirmed staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. For example, the number of antimicrobials issued by the provider was lower than local and national averages. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.

People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms. Staff received regular training, were competency assessed on medicines optimisation. Prescription stationery was stored securely.

During our onsite visit, we reviewed the emergency medicines and equipment and identified areas for improvement to strengthen safety and accessibility.

We found emergency, medicines and equipment did not consistently align with inventory lists, with variations identified between emergency kits on both floors.

We found medicines cupboards containing non-emergency prescription medicines were unlocked within access-controlled utility rooms. A risk assessment to support these storage arrangements was not available at the time of inspection.

As part of our assessment, we carried out clinical searches of the provider records.

Our clinical searches reviewed the number of patients prescribed a medicine used primarily to treat high blood pressure and protect kidney function (ACE inhibitor or Angiotensin II reception blocker). We reviewed 5 patient records and found that 2 patients had not had their appropriate blood test monitoring in line with the guidance. The practice acknowledged this feedback and had repeatedly invited both patients for monitoring, and had since contacted the patients involved.

As part of the searches we reviewed whether the practice was actioning Medicines and Healthcare Products Regulatory Agency (MHRA) safety alerts. We randomly reviewed 5 patients that were prescribed a medicine(febuxostat) and also had a history of cardiovascular disease. We found that 2 patients had not been informed of the risks associated with this medicine.

We reviewed the use of pain relief medicine (non-steroidal anti-inflammatories) in patients aged over 65, and medicines used to prevent blood clots (antiplatelet) in patients aged over 75. National guidance recommends to consider a stomach-protecting medicine (PPI) to these patients. We reviewed a random sample of 5 patient records. We found that all 5 patients reviewed had not been assessed to see if they would benefit from the recommended medicine, potentially putting them at risk.