Anchor Medical Practice Also known as Netherton Health 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

Since the last assessment, we found some improvements had been made to ensure risks were mitigated. The practice had taken action to ensure there were safe systems and processes for learning, recruitment and staff immunisation status. Previously we had identified there was no formal audit activity of non-medical prescribers to ensure their competency, at the time of the last inspection in October 2023, we received evidence to demonstrate that formal processes were in place to monitor the prescribing activity of staff in advanced clinical roles. However, during this assessment we found non-medical prescribers employed by the Primary Care Network (PCN) were not being monitored by the practice to ensure they had the appropriate competencies for prescribing medicines. Following the assessment, we received assurances that a review was taking place to ensure all risks were mitigated.

We found action had been taken to ensure people’s safety was integral to the care and treatment they received. All staff understood the importance of keeping people safe and where there were concerns identified about people’s safety these were actioned promptly, and improvements made.

We have rated the practice as good for providing safe services as following the on site assessment, the provider provided us with assurances that staff with advanced roles working at the practice through arrangements with the PCN, would be reviewed and the appropriate monitoring would be in place to ensure safe care and treatment was provided to people.

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.

Staff and leaders understood their duty to raise concerns and report incidents and near misses. Staff were involved in investigating significant events and complaints and identifying learning. We saw evidence that any actions or lessons learned was discussed in practice meetings. Staff and leaders were able to share examples of incidents and complaints which had been investigated and staff told us they felt they were able to raise concerns and report when things went wrong. Feedback from staff and leaders demonstrated that the practice had a culture of identifying incidents and complaints, learning and improvement to continually identify and embed good practices.

The practice had a significant events policy and a reporting form which was accessible to all staff members. The practice had a significant events lead responsible for supporting staff in identifying and reporting significant events. The practice followed their significant events policy and discussed events and incidents during team meetings and learning was shared with staff. The practice had a duty of candour policy and involved people when managing significant events and errors. The practice had a clear system in place to record and investigate complaints. From the sample of complaint records we reviewed; we found the practice responded to people’s complaints in a timely manner. The practice offered apologies to people, lessons were learnt from individual concerns and complaints and action was taken as a result to improve the quality of care.
 

Leaders told us that 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 documents, laboratory test results and referrals were reviewed and actioned in a timely manner. We found that test results were managed in a timely way and all workflow was followed up and actioned appropriately.

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 PCN and attended regular meetings with other agencies across the locality to share and discuss information relating to patient care and treatment.

We found safe systems of care, in which safety was managed and monitored. For example, there was a system for processing information relating to new patients including the summarising of new patient notes and a documented approach to the management of test results. There were systems in place for referrals to appropriate services, which was managed in a timely way.

At the last inspection in October 2023, we had identified a range of staff who had not received a Disclosure and Barring Check (DBS). At this assessment we found effective processes were now in place to ensure staff had the appropriate checks in place prior to employment. 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 or in the absence of a DBS there was a documented risk assessment to explain why a recent DBS was not required. 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 practice had a safeguarding lead for adults and children and policies in place to support staff in the event of a safeguarding concern. Staff we spoke knew of the policies and procedures available to support them and what to do if they had any concerns about a patient. We were told that the practice reviewed safeguarding in practice meetings and that children and young people who were not brought to their appointments were followed up. The practice held a safeguarding register, and clinical system alerts were used to identify patients who were at risk of harm or abuse. Staff were aware that these flags could indicate a potential risk. The practice attended regular multi-disciplinary meetings as part of the PCN to review vulnerable patients.
 

Leaders told us that they worked with services locally to understand and manage risks. For example, there were regular primary care meetings held with other agencies to work holistically so that care met patients’ needs and services managed care holistically. 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.

There were processes in place to ensure the practice prioritised care for their most clinically vulnerable patients and patients were told when they needed to seek further help and what to do if their condition deteriorated. There were systems in place to support patients who face communication barriers to access treatment (including those who might be digitally excluded).
 

Leaders told us that that health and safety, security and maintenance of the building was regularly reviewed to ensure this was to a safe standard. 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.

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. The premises were managed by NHS property services who regularly carried out a schedule of routine maintenance for the building in line with health and safety. A fire risk assessment had been completed by NHS property services in July 2024. At the last inspection in October 2023, we found the practice did not carry out their own health and safety audits or risk assessments, at the time of the inspection in 2023 we were told by the provider, they would carry out an annual audit of their section of the building, however, following this assessment the provider was unable to provide evidence that this process was in place. We were assured however, that regular checks were completed by the landlords.

During our site visit we found the premises were well maintained. There was building work taking place inside the premises to increase the number of consultation rooms and also provide a new reception area. We found there was clear signage and procedures in place to ensure the safety of everyone using the building during this time.

Fridge temperatures were recorded daily, and a data logger was in place which was reviewed regularly to ensure the fridge temperatures were within a safety range. All staff had completed health and safety training. This included basic life support and sepsis awareness. 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.

At the last inspection in October 2023, we found the systems for the recruitment of staff and ensuring staff had the appropriate immunisation status required strengthening to mitigate risks. At this inspection we found processes had been implemented to ensure effective recruitment procedures were in place. This included DBS checks for staff where deemed appropriate and in their absence risk assessments had been completed.

There were policies and procedures in place for the safe recruitment of staff which had been reviewed further since our last inspection. The provider told us they had completed DBS checks for all staff working in the practice and that all newly employed staff had completed an induction to ensure they were competent in carrying out their role. There were clearly defined lead roles to support staff in carrying out their roles effectively and staff were supported by leaders. The practice had a programme of learning, which was monitored by the management team. We found that staff were up to date with training requirements, which included newly appointed staff. There were staffing rotas to ensure there were adequate cover in place. On speaking with staff, we were told there were enough staff on duty to cover busy periods and for staff absences.

We reviewed 4 personnel files and found appropriate checks such as previous employment record, proof of identity and clinical staff files had evidence to demonstrate that clinical registration checks had been completed. Personnel folders were well organised and there was a systematic approach to ensure that personnel folders were managed appropriately. We found staff immunisation status records were in place.

We found that processes had been reviewed for supervision and oversight of staff in advanced clinical roles, however we were unable to gain assurances that staff who were working at the practice through the PCN were adequately supervised. We identified concerns in the prescribing of some medicines and at the time of the assessment there was no clinical oversight to demonstrate the appropriate checks had been completed prior to issuing the prescription. Following the on site assessment we received assurances that a review was taking place of staff not directly employed by the practice.

We observed the general environment to be clean and tidy and cleaning rotas were in place. Sharps bins were available in all clinical rooms which were signed, dated, safely placed and were not over-filled.

The practice had policies in place for infection, prevention and control which was accessible to staff and staff are aware of the action to take. For example, in the event of a sharps or contamination injury. There was an infection control lead in place and an infection control audit had been carried out in October 2024; the practice had achieved 88%. On reviewing the infection control action plan, we found that actions had been completed. For example, clinical waste bags were now being labelled with the appropriate details. Since the last inspection in October 2023, we found at this assessment that all staff were up to date with training relevant to their role.
 

The practice worked with the clinical pharmacists from the local PCN and the lead GP reviewed their prescribing and management of patients receiving high risk medicines and medicines which required monitoring. However, as part of the assessment we carried out a remote clinical review where we identified potential clinical coding issues. We carried out a clinical search to identify people who had received a medication review in the past 3 months. The searches identified potentially 258 people in this category. We reviewed a random sample of 5 clinical records and found 3 out of the 5 records we reviewed showed the required monitoring was not up to date. The clinical review also highlighted non-clinical staff had coded medication reviews as having been completed. We carried out a remote clinical search for a safety alert that had been issued concerning a medicine that had increased risks for people aged over 65 years if they were on a higher dose. The clinical searches showed potentially 9 people who were on this medicine and on higher than the recommended dosage. We reviewed a random sample of 5 clinical records and found all 5 patients were on a higher than recommended dose and none had been made aware of the risks. A further review showed that staff in advanced clinical practice working for the PCN had changed the dosage of the medicine to a higher dose and this had been agreed by a clinical practitioner. We found no evidence to demonstrate that the safety alert had been considered, or action had been taken to review the patients. Following the on site assessment, the clinical lead was reviewing the clinical searches to identify actions that were required.

We completed a clinical search to identify patients who had been prescribed 10 or more prescriptions in the past 12 months of a group of medicines called Benzodiazepines, which are used to treat anxiety and sleeping problems. The search identified 22 people. We reviewed a random sample of 5 records and found 3 out of the 5 records seen, people had not been informed of the potential risk of addiction.

During the remote clinical review, we reviewed people who had been prescribed high risk medicines. This included methotrexate, used to treat rheumatoid arthritis and which requires regular blood monitoring due to the risk of side effects. We found there were 44 patients who were prescribed this medicine and potentially 2 patients who had not received regular monitoring. However, on reviewing these clinical records we found the patients were being monitored by the hospital. A further review of the clinical system identified 44 people on Warfarin. A medicine used to treat blood clots and reduce the risk of heart attacks and stroke which requires regular monitoring. Our review found all patients on this medicine were being monitored appropriately.

All emergency equipment had been reviewed and were appropriately stored with clear monitoring processes in place. There were appropriate arrangements in place for the management of vaccines and for maintaining the cold chain. We saw fridge temperatures were routinely monitored and vaccines reviewed at random were in date and stored appropriately. The practice held appropriate emergency equipment and emergency medicines which were checked on a regular basis. Vaccines were ordered and stored in accordance with national guidelines and the practice had systems in place to monitor the temperature of vaccine fridges.

Our review of patient records in relation to the clinical searches identified that care records were managed in line with guidance and legislation. The practice had systems for monitoring two week wait referrals to ensure patients were seen and held multidisciplinary meetings with other agencies to share and discuss information relating to patient care and treatment, for example, those on the practice palliative care register.