Black Country Family Practice

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.

We found the monitoring of some medicines required further strengthening, however we were assured that the clinical leadership team were aware of the concerns identified and had an action plan in place to ensure patients were regularly reviewed. Systems were in place to protect individuals from abuse and avoidable harm. We found safeguarding procedures were in place and safety was clearly prioritised across the service.

Health and safety procedures were regularly monitored, and the premises were appropriately maintained. Any actions identified were acted on to reduce potential risks.

We found safety incidents were investigated, and the process for sharing learning had been strengthened to identify shortfalls and prevent recurrence and regular practice meetings were in place where learning was shared with the practice team to mitigate any future risks.

This service scored 72 (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. They listened to concerns about safety and investigated and reported safety events.

Managers encouraged staff to raise concerns when things went wrong. Staff felt there was an open culture, and that safety was a top priority. The provider had processes for staff to report incidents, near misses and safety events.

The practice had a significant events policy, and a reporting form was in place, which was accessible to all staff members. A regular review of incidents was carried out to monitor any specific trends. Daily huddles were held with all staff to discuss any significant events or incidents that had occurred to ensure learning was shared quickly to mitigate any future risks.

Information reviewed demonstrated that people had opportunities to provide feedback, however patients we spoke with were unaware of how to make a complaint. Information on how to complain was available on the practice website and in the waiting room. Lessons were learnt from individual complaints and shared with the practice team to improve the quality of care.

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.

Effective systems were in place for processing information relating to new people including the summarising of new records. We found clinicians made appropriate and timely referrals in line with protocols and up to date evidence-based guidance. This was supported by a system in place to ensure all patient information including laboratory test results and referrals were reviewed and actioned in a timely manner.

The provider told us that there were processes in place that was monitored and managed to keep people safe. For example, the provider was part of the primary care network (PCN) and attended regular meetings with other agencies across the locality to share and discuss information relating to patient care and treatment.

There were a range of structured meetings in place. These included safeguarding, multi-disciplinary and practice team meetings. Daily huddles were held for all staff to have the opportunity to discuss any concerns, and the leadership team had the opportunity to discuss and share learning from incidents and complaints.

The service 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 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. On reviewing the safeguarding registers, we found alerts were added to each record to identify safeguarding concerns, however families were not linked to ensure all staff were aware of that there was someone in the household who was on the safeguarding register. We received assurances on the day of the onsite assessment that this would be actioned.

There was a safeguarding lead for children and adults and all staff were aware of who to speak to if they identified a safeguarding concern. The service 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 service shared concerns quickly and appropriately.

There were processes in place to follow up children and young people who were not brought to their appointments with the provider and for secondary care appointments and safeguarding meetings were held on a regular basis to review people at risk. Community teams were invited and attended on occasions; however, they ensured information was shared appropriately for the care of people with safeguarding and vulnerable concerns.

There was a policy in place for the renewal of DBS checks. Records we examined showed that all staff had a DBS check in place. DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable.

The service 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 could recognise a deteriorating patient and knew of action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

Leaders told us that they worked with services locally to understand and manage risks. The practice also had registers in place to support those patients who were vulnerable or who had mobility or communication needs.

All staff were trained in basic life support and receptionists were aware of actions to take if they encountered a deteriorating or acutely unwell patient and had been given guidance on identifying such patients.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Health and safety related assessments and procedures to manage health and safety were in place. We found a range of risk assessments had been completed in throughout the year, which included fire safety, electrical safety, premises security, legionella, office safety and hazardous waste. A plan was in place to monitor the premises to mitigate risks. For example, storage of flammable liquids. Regular monitoring was in place to ensure guidelines were adhered to and all staff had been made aware of the appropriate procedures to follow.

There were policies and procedures in place for the management of health and safety. Fire safety policies were in place and staff were aware of how to access these. 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.

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 hazardous substances. Evidence provided by the practice showed equipment was regularly calibrated and electrical items were PAT (portable appliance testing) tested in November 2024.

There was a business continuity plan in place which was monitored and reviewed. Reception and administration staff who handled calls to the practice and arranged appointments with the clinical team were aware of potential red flag symptoms. Staff knew when to notify a GP or other clinicians with concerns about a patient who may be acutely unwell and/or deteriorating.

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. Cleaning schedules were in place and followed. Control of Substances Hazardous to Health (COSHH) risk assessments were in place and all cleaning products and equipment were stored appropriately. Clear signage around the building supported people and staff in the event of an emergency evacuation.

The service 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.

Evidence provided demonstrated systems were in place for the monitoring of staff, which included regular conversations as part of their clinical supervision. 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.

The practice had recruitment policies in place, and all staff had completed disclosure and barring checks. All newly employed staff had completed an induction to ensure they were competent in carrying out their role. As part of the Modality Partnership, all personnel folders were held centrally and all recruitment was managed through the centralised team. We reviewed 3 personnel files and found appropriate checks such as previous employment record and proof of identity checks had been completed. Personnel folders were well organised and there was a systematic approach to ensure that personnel folders were managed appropriately. The appropriate checks had been carried out for the immunisation of staff.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

An infection control audit had been completed to identify potential risks and take appropriate action where required. The latest audit had been completed in June 2025, and the practice had achieved 96%. An action plan was in place and we found identified areas for action had been acted on. For example: One of the pillows in a consultation room was found to be absorbent and would allow for any fluids to pass through it, therefore it would not be decontaminated effectively. The practice had removed the pillow from the room and disposed of it.

The practice had a designated infection, prevention and control lead and all staff had completed training relevant to their role. Staff were aware of the systems and processes to follow to ensure clinical specimens were handled safely.

The practice had policies in place for infection, prevention and control which was accessible to staff and staff were aware of the action to take. For example, in the event of a sharps or contamination injury.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

The practice had clinical pharmacists and also worked with the clinical pharmacists from the local primary care network (PCN) to monitor people and the prescribing of medicines. We carried out a remote clinical review of patients who had been prescribed 10 or more prescriptions of medicines called benzodiazepines, used as a sedative for the treatment of conditions such as anxiety. The search identified 37 patients. We reviewed a random sample of 5 records and found 1 patient where there was no evidence to demonstrate that weaning off the medicines had been attempted.

We reviewed the processes in place in relation to safety alerts issued by the Medicines and Healthcare products Regulatory Agency (MHRA). For example, we carried out a clinical search to identify women of childbearing age prescribed Topiramate, a medicine used for the treatment of epilepsy, that has the potential to increase the risk of birth defects. The clinical search identified potentially 33 patients on this medicine. We reviewed a random sample of 5 patients and found 1 had no contraceptive advice recorded in their records or evidence to demonstrate they were aware of the risks.

Emergency medicines, vaccines and medical equipment had clear monitoring processes in place. There were appropriate arrangements for the management of vaccines and for maintaining the cold chain of the vaccine fridges and a data logger was also in place. We saw fridge temperatures were routinely monitored and vaccines reviewed at random were in date and stored appropriately. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments.

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 took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. Prescribing data reviewed as part of our assessment confirmed this. For example, the number of antimicrobials issued by the provider was in line with local and national averages.