The Heron GP 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 inspection, we rated this key question as requires improvement. At this inspection, the rating has remained requires improvement, despite some improvements being made. The provider had made improvements in the following areas: management and appropriate use of patient specific directions, management of the cold chain and blank prescription stationery and oversight of emergency medicines stock. However, whilst we did not find a breach of regulation, there was still improvements to be made in relation to maintaining records of staff immunisation status.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

At our previous assessment in March 2022, we found that the provider did not require non-clinical staff, in direct contact with patients, to be immunised (or demonstrate existing immunity) for specific diseases and infections, in line with national guidance. During this assessment, the provider was able to provide assurances to demonstrate risks had been minimised. We saw evidence of comprehensive recruitment systems that incorporated staff immunity status checks for newly recruited staff. Leaders advised that they had identified there were still some gaps in capturing and recording evidence for all staff, particularly those historically employed. They provided detailed evidence of action taken to resolve this;including implementation of appropriate risk assessments for specific staff as needed and a dedicated programme to ensure all actions would be completed within 3 months of this assessment.They also committed to undertaking routine audits of compliance and annual reviews for staff aligned to seasonal vaccine arrangements, with clear accountability systems in place.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

At our previous assessment in March 2022, we found gaps in systems and processes designed to ensure patient and staff safety in relation to medicines. During this assessment,we found that risks had largely been minimised.

Previously,we found that there were gaps in processes to manage prescription stationery appropriately and securely.The provider was able to demonstrate these processes were now improved and effective systems were now in operation.

In addition, we identified risk assessments relating to emergency medicines not stocked by the provider were lacking. During this assessment, the provider was able to demonstrate how emergency medicine stocks had been carefully considered through suitable governance systems, with appropriate risk assessment where needed.Evidence provided demonstrated identified actions were taken promptly.

Previously, we saw the practice used patient specific directions (PSD). We saw these were in place to authorise the health care assistants to administer influenza, pneumococcal or shingles vaccines. However, PSDs were not in place to authorise the health care assistants to administer other injections, for example, vitamin B12 injections.During this assessment, we were provided with assurance that effective governance systems had been established to monitor PSDs and reduce identified risks. We saw evidence of an audit undertaken for a 2-year period,between January 2024 and January 2026. This audit had identified 96% compliance with the practice’s processes to ensure appropriate use of PSDs for vitamin B12 injections. In response, the practice had updated standard operating procedures, sharing them with the team to improve compliance further.

During our last assessment, we found the process for monitoring safety of vaccines and medicines stored in fridges needed improving. Specifically,evidence that fridge temperatures were checked daily, and appropriate action taken to temperature breaches was lacking. For this assessment, the provider demonstrated improvements in safety systems. We saw there were digital data loggers in place to record fridge temperatures and improvements had been made to ensure daily checks. Further risks were identified by leaders whilst preparing for this assessment and the provider took swift action to address them; it was noted that during unexpected staff absence fridge checks were occasionally not being done. In response, more staff were trained and assigned responsibility for checking temperatures and undertaking actions if needed.