Baddeley Green 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

The service had a good learning culture and people could raise concerns. People were protected and kept safe. Staff understood and managed risks, however, some opportunities for reporting and learning from incidents had been missed. The facilities and equipment met the needs of people. During the assessment however, we found not all equipment had been in receipt of recent maintenance or a portable appliance test. The provider immediately following this feedback ensured these were 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 support high-quality care. There were gaps in the care navigation information prompts/guidance and in the competency process for reception staff inductions. Actions to improve these processes were immediately put in place following the inspection and evidence provided to the Care Quality Commission. We found there was a system in place for checking medicine expirydates but not for stock levels, with one exception. Measures were put in place following the inspection.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. Representatives from the Patient Participation Group (PPG) found the provider took concerns seriously and proactively made improvements to the service. Leaders encouraged staff to raise concerns when things went wrong. During staff meetings, the whole team discussed and learnt from clinical and reception administration issues. The provider had processes for staff to report incidents, near misses and safety events. However, some opportunities for reporting and learning from incidents had been missed. For example, a reported accident within the practice had not triggered a significant event.

There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Leaders told us they acted on all verbal complaints received; however, the information and outcome was held within the patients record. Therefore, verbal complaint monitoring and trend analysis was not auditable. Learning from incidents and complaints we reviewed had resulted in changes that improved care for others.

The practice worked in partnership with the multidisciplinary community team. Minutes from these meetings showed that patients were involved in making decisions about their care and treatment. Where patients, did not wish to engage with these services for additional support, patients’ decisions were respected. Appropriate referrals were made to health and social care services as required.

There were systems in place for processing information relating to new patients. The service worked with other providers to deliver shared care and when patients moved between services. Referrals and test results were managed in a timely way.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. Staff were aware of the processes to follow if they identified a potential safeguarding concern and how to access appropriate safeguarding policies for support. The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations. Discussions took place around children with emerging health care needs and immunisationuptake. There was a named safeguarding lead within the practice with deputising arrangements in place and a system of identifying those patients with a safeguarding concern.

Staff were aware of where emergency medicines and equipment were kept in the case of a medical emergency. Risk assessments had been completed to determine the range of emergency medicines held within the practice and a system to monitor expiry dates was in place. However, there was no system in place for the medicine stock levels, with one exception. Following the inspection the practice implemented a medicine stock check process. There was medical oxygen and a defibrillator on site and systems were in place to ensure these were regularly checked and fit for use.

Some of the information to support non-clinical staff taking patient incoming calls lacked detail. For example, staff told us all children were seen for an appointment on the same day. However, the guidance in place did not specify this in order to support new or inexperienced staff. We fed this back to the leadership team and the information for reception staff was promptly updated and rectified following the inspection.

Leaders reviewed frequent attendees to accident and emergency departments. Emergency department letters received by the practice were reviewed to identify patients who had been admitted to hospital with suicidal concerns. Where required, referrals were made and patients’ needs discussed at multi-disciplinary meetings. Leaders shared examples of collaborative working and information sharing with community teams to provide additional support and access to services for patients when needed.

Staff we spoke with told us they were trained in emergency procedures such as fire safety. They told us their training had included details of actions to take to promote fire safety and fire checks were carried out within the practice. Staff had attended additional training for their role as a fire marshal. 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.

On site we found that not all electrical equipment had been labelled as having been in receipt of a recent portable appliance test. The leadership team acted on this information by reviewing the assets list and contacting the relevant company to attend and review. The clinical couches and wheelchair had no recent maintenance records. One couch had a small tear in the fabric. We found that window blinds with a cord had no risk assessment or risk reduction measures in place which was brought to the practice attention for actioning. These were actioned immediatelyfollowing the inspection. Leaders advised that areas for refurbishment and maintenance such as the carpet in the annex building would be added to the maintenance log. Limited car parking was available at the site and included disabled car parking bays. There was a business continuity plan in place which was monitored and reviewed.

There were a range of clinical and non-clinical roles within the practice. Staff had access to on line and face to face training. Staff with extended or additional roles had completed additional training. Learning disability and autism Part 1 of 2 training had been completed for all staff and some clinical staff had completed part 2. However, part 2 training was being sourced for all remaining staff.

The practices mandatory training was for the vast majority of staff was up to date. An induction policy was in place and role specific induction documents were held on the practices electronic system. We found there was a lack of reception induction documentation, including staff competency completion reviews for their role. Those that were partially completed were not held in staffs personnel files to enable governance and oversight. The practice leadership following the inspection put governance measures in place to enable oversight and forwarded a copy of their action plan.

Staff received reminders when due their training or refresher updates. Staff with extended roles worked within their agreed areas of competence. Learning needs and development of staff was managed and reviewed during staff appraisals and at clinical supervision sessions. Recruitment practices were followed.

The practice had a designated infection, prevention and control lead and all staff had had relevant training. Cleaning schedules were in place and followed. We found the cleaning schedule sheets did not specify which consult room had been cleaned for the practice audit purposes. The consulting couch with a tear in the fabric was brought to the practices attention and action was completed by 27 June 2025. Dust seen on some of the blinds were reported by leadership to the domestic team for actioning on the day of the inspection. Risk assessments and audits were completed, and actions taken to mitigate risks.

We observed that the arrangements for managing waste kept patients safe. The Control of Substances Hazardous to Health Regulations (COSHH) risk assessments were in place for staff to refer to. However, in the staff area we found COSHH products, which were then removed by the practice staff. There was a need for some minor refurbishment to the staff toilet facilities.

The provider had effective systems to manage and respond to safety alerts and medicine recalls. Clinical staff we spoke with understood how to deal with these. Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring. Leaders told us alerts on the electronic patient records were used to inform staff when patients were prescribed high risk medicines. When patients did not engage with medicine reviews, leaders told us there were systems in place to address this.

A non-medical prescriber told us there were regular reviews of their prescribing practice supported by clinical supervision and auditing of the effectiveness of their consultations and prescribing. Staff followed protocols to ensure they prescribed all medicines safely, and ensured people received recommended medicines reviews and monitoring. Medicines including controlled drugs were stored securely and at appropriate temperatures. Staff regularly checked expiry dates for all medicines, including emergency medicines, vaccines and medical gases, such as oxygen. These were stored safely and staff completed required safety risk assessments.

Vaccines were appropriately stored and monitored in line with UK Health Security Agency (UKHSA) guidance to ensure they remained safe and effective. When vaccines had been affected by a break in the cold chain, appropriate action had been taken by the practice. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.

Blank prescriptions used in clinical rooms were kept securely. However, the system to record and track other prescription stationery held was not readily auditable. Following our assessment the provider sent us evidence of the new system they had implemented.

Our clinical searches found 1 out of 4 patients on a specific teratogenic medicine without evidence seen of a discussion around contraception use or the risk at their medicine review. (Teratogenic medicines have the potential to interfere with normal foetal development during pregnancy). Following the inspection the provider immediately followed this up and provided evidence of their actions.

Our clinical searches found 2 patients, aged 65 years plus on a specific antidepressant medicine and we sampled these records. We saw the potential for risk in that patients had not had an electrocardiogram (a test that records the electrical activity of the heart). The provider booked for these patients to have this test.

Patients prescribed Direct Oral Anticoagulants (DOACs) were monitored and managed by secondary care. In light of our clinical search findings the provider agreed to write to the haematology and renal team regarding 2 patients’ blood monitoring levels for the practices governance and audit insight purposes.