Dr Onn Syed Also known as Stopgate Lane 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 looked for evidence that people were protected from abuse and avoidable harm. We assessed all quality statements under this key question. At the last inspection we rated this key question as good. At this assessment we have rated this key question as requires improvement.

This is because some of the systems in place for incident management, for health and safety related checks and for safeguarding people against the risk of abuse or avoidable harm were not fully established.

There were sufficient numbers of suitably trained and qualified staff who were well supported in their role.

There were processes for monitoring patients’ health in relation to the use of medicines including medicines that required regular review. However, some processes required improvement, for example ensuring all patients underwent the required monitoring before medicines continued to be prescribed.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

A learning culture was evident and staff felt confident to raise concerns. We noted that there had been learning from significant events and incidents, however there was no formal system for reporting and recording these.

Staff felt there was an open culture, and that safety was a priority.

Staff told us they felt well supported with training to meet their roles and responsibilities and a system was in place to monitor staff compliance with mandatory training. Training was provided within the service and through attendance at locality wide training and educational events as required.

A system was in place to manage and respond to medicines safety alerts and medicine recalls. The system in place for managing other safety alerts did not provide an audit trail for actions taken.

The provider worked alongside other stakeholders and worked within the Primary Care Network (PCN) to develop services.

The provider worked with people who used the service and healthcare partners to establish and maintain safe systems of care. There were systems and processes to share information with staff and other agencies to enable them to deliver safe care and treatment.

Feedback from people who used the service indicated they felt involved in decisions about treatment pathways and they reported prompt follow up care.

Members of the staff team were aware of local services and support networks that they could refer patients to in order to support them with their needs and to prevent ill health.

Clinicians followed care and treatment pathways for treating and referring patients to other services. Referrals to secondary or specialist care were made promptly, and patients referred for urgent investigations were followed up appropriately. Correspondence from secondary care such as discharge letters/summaries were processed quickly and effectively.

Staff had been provided with safeguarding training at a level that was appropriate to their roles and responsibilities. Staff had a clear understanding of safeguarding and were able to tell us who the responsible lead for safeguarding was. They knew the action to take if they had concerns about a patient’s safety and they told us they would feel confident to report concerns. Alerts were added to the patient record system when a patient was subject to a safeguarding concern so that all relevant members of the staff team could readily identify this. However, we noted that alerts were not always added for household members where this may be relevant to safeguarding. The provider should also review the safeguarding register and consider improving the information contained in this to ensure the coding of patients in the patient record system is accurate. The provider should also have a system in place to monitor missed appointments and AE attendance where safeguarding concerns have been noted.

Feedback from people who used the service did not include any concerns with regards to safeguarding.

The service worked with people to understand and manage risks. The care and treatment provided was safe, supportive and encouraged people to remain healthy. Patients were advised on risks related to their condition and actions to take if their condition deteriorated. Staff were trained in areas to support people who lived with long-term health conditions, for example, diabetes. Patients were called in for regular checks on their health when they were living with a long-term condition.

The provider encouraged patients to attend for health screening. People who had not attended for cancer screening were followed up and encouraged to attend. Childhood immunisation uptake was below World Health Organisation targets, but the provider worked actively to encourage uptake and improve this.

The service was located in a building that had been adapted for purpose. Some of the arrangements for detecting and controlling risks in the environment and managing health and safety were not fully effective. We noted a range of assessments and checks that had been carried out recently and there was no evidence of the date of previous checks. For example, checks on electrical equipment and calibration of equipment. This did not provide assurance that an effective system was in place to ensure that all required checks were being carried out at appropriate intervals.

Staff had been provided with training in health and safety related topics such as fire safety, infection control and manual handling. Staff told us in discussions and feedback forms that they had no concerns with the arrangements in place for ensuring health and safety.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and opportunities to develop. Staff told us they had received training appropriate and relevant to their role and a system was in place to monitor staff compliance with mandatory training.

Patients benefited from a stable clinical team, resulting in consistent care and treatment. Staff in all roles told us there were enough staff to provide safe, high-quality care and they worked effectively as a team. There were arrangements in place for covering staff sickness, absence and vacancies and the use of temporary staff was minimal.

Feedback from people who used the service that was shared directly with CQC was positive with comments indicating high levels of satisfaction with members of the staff team and with access to clinicians.

Staff recruitment procedures were in place to ensure staff were appropriate to work in the service. However, the provider should ensure proof of qualifications and immunisation status has been obtained for all staff as required for their role.

The facilities and premises were appropriate for the provision of clinical care and to minimise the spread of infection. Personal protective equipment was in good supply and located appropriately around the premises.

Cleaning schedules were in place and cleaning equipment was stored securely and in line with best practice.

A lead person was responsible for infection prevention and control. This role had been assigned to a member of the clinical team following our visit. External infection prevention and control audits had been carried out but there was no system for auditing this aspect of the service between these. The provider told us they planned to address this in response to our findings.

The provider made sure that medicines and treatments were safe and met people’s needs overall. We reviewed clinical records for patients who had been prescribed medicines which required routine monitoring. Our review showed that medicines were managed safely overall and staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring. We noted that a small number of patients were overdue checks relating to their medicines. The provider outlined immediate actions following our assessment including; improved recording of patient contact attempts and recall, enhanced monitoring of patients prescribed high risk medicines, clearer escalation for missed reviews, appropriate prescription quantity restrictions for high-risk medicines and strengthened documentation of medication reviews.

Prescribing data was monitored to improve prescribing in areas where this had been higher than average. For example, broad spectrum antibiotics and multiple psychotropics.

Staff had access to emergency medicines and equipment including oxygen and a defibrillator. These were regularly checked for stock availability and to ensure they were in date. Vaccines were stored appropriately, and regular checks were carried out to ensure safe storage and stock.

A system was in place to manage and respond to medicines safety alerts and medicine recalls.