Penvale Park 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 reviewed the practice’s policies, spoke with staff via video calls, and carried out on-site observations to assess the safety and quality of care.We looked for evidence that people were protected from abuse and avoidable harm.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 practice had clear processes for reporting incidents, near misses, and other safety events. There was evidence to demonstrate a proactiveand positive culture of safety, based on openness and honesty.The provider had processes for staff to report incidents, near misses and safety events. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

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.

The practice worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. There were systems in place for processing information relating to new patients.They made sure there was continuity of care, including when people moved between different services.Referrals and test results were managed in a timely way.

The practice worked well with people and healthcare partners to fully 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 service shared concerns quickly and appropriately.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 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.Emergency equipment was available and maintained. 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.

Staff were aware of their responsibilities to maintain a safe environment and understood their role in responding to emergencies. All staff had completed appropriate safety training relevant to their roles. The practice had policies and procedures in place to ensure that equipment, facilities, and technology supported the delivery of safe care. Health and safety risk assessments had been completed, and appropriate actions were taken to mitigate identified risks. During our onsite visit, clear signage throughout the premises supported staff and patients in the event of an emergency evacuation. The premises were visibly clean and well maintained. Portable appliance testing (PAT) and equipment calibrations were up to date. Systems were in place to check and maintain fire safety equipment, including alarms and extinguishers, to ensure they remained in good working order.There was a business continuity plan in place which was monitored and reviewed.

Practice leaders 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. 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. Safe recruitment practices were followed.

Staff were aware of their infection prevention and control (IPC) responsibilities and who the IPC lead was should they need additional support. Staff knew how to manage clinical waste and specimens. Cleaning schedules were in place, and the premises were visibly clean. They detected and controlled the risk of infections spreading and shared concerns with appropriate agencies promptly. Risk assessments and audits were completed, and actions taken to mitigate risks.

The practice made sure that medicines and treatments were safe and met people’s needs,capacities and preferences. They involved people in planning, including when changes happened.As part of our assessment, remote clinical searches were conducted by one of our GP Specialist Advisors. During the clinical searches, we found evidence of effective systems and processes to support medication reviews and appropriate monitoring of patients. Evidence demonstrated staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely. 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, and felt confident managing the storage, administration and recording of medicines. Staff managed prescription stationery appropriately and securely. Staff followed protocols to ensure they prescribed all medicines safely, and ensured people received all recommended medicines reviews and monitoring. Medicines were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines, vaccines, and controlled drugs. Waste medicines were recorded and disposed of appropriately including medicines returned by patients. Staff stored medical gases,such as oxygen, safely and completed required safety risk assessments.

The provider had effective systems to manage and respond to safety alerts and medicine recalls. Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring.For example, we reviewed patients prescribed a specific medicine used to treat autoimmune conditions.Our searches identified 3 patients taking this specific medicine and we reviewed records for all 3 of these patients and found evidence the practice was supporting these patients appropriately. 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.