Favell Plus Surgery

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• 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 the quality statements from this key question. The practice had some systems to assess, monitor and continue to improve the quality and safety of service However, evidence of effective management oversight was limited and there were system gaps that could pose a risk to patient safety. There were processes for monitoring patients’ health in relation to the use of medicines including medicines that require regular reviews. We found some of these systems and processes needed further review to reduce potential risks to patient safety. This key question has been rated as Good.

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.

The practice 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. Lessons were learnt to continually identify and embed good practice. People felt supported to raise concerns and felt staff treated them with compassion and understanding. Representatives from the Patient Participation Group (PPG) felt the provider took concerns seriously and proactively made improvements to the service. Managers encouraged staff to raise concerns when things went wrong. Staff felt there was an open culture. The provider had processes for staff to report incidents, near misses and safety events. Significant event reporting forms were available to all staff to access from the practice computer system. Leaders advised there was a Freedom to Speak Up (FTSU) policy but were unable to confirm there was a named Freedom to Speak Up Guardian. During this assessment, the practice submitted an up-to-date FTSU policy which clearly identified the appointed freedom to speak up guardian. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Learning from incidents and complaints resulted in changes that improved care for others. The leadership team did not review complaints and learning events annually to see if there were trends that needed further action or investigation. There was no formal log of complaints and significant events. Instead, the practice used minutes from meetings to record actions taken in response to complaints.

The service worked with people and healthcare partners to establish and maintain 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. However, we found gaps in these systems. We were informed there was a significant backlog of patients’ clinical notes from their previous GP practices’ which required summarising. This amounted to between 4,327 and 7,900 sets of notes which required summarising dating back to 2016. The practice had assessed the associated risk as low as there was a system for digitised clinical notes to be summarised when patients transitioned between GP practices. There was a risk that information in paper clinical notes which had not been digitised would not be included on some patients’ records, meaning clinicians would be able to obtain a full medical history prior to planning and delivering care. Practice leaders advised for patient notes that had been summarised, appropriate digital coding had not been used making it difficult to know accurately how many records required summarising. They advised work to rectify this would be prioritised. Following our assessment, the practice submitted a protocol for how they would process summarising of new patient records in future.

The practice 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. All staff we spoke with understood their responsibilities around safeguarding. A random sample of staff files we reviewed showed all staff had a suitable Disclosure and Barring Service (DBS) checks based on the role and responsibilities of the job. The DBS checks whether a prospective employee has a criminal record or has been barred from working with children or vulnerable adults, depending on the level of check carried out. The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations. Regular safeguarding meetings were held with the local multidisciplinary team such as health visitors. Staff were aware of safeguarding issues specific to their practice population. Appropriate clinical coding was used to flag people on the safeguarding register and their family members.

The practice 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. In the 2025 national GP patient survey, 91% of people who responded said they were involved as much as they wanted to be in decisions about their care and treatment. This was in line with the national average. 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. There was always a duty GP available if they needed urgent advice. Emergency equipment was available and maintained. However, we found record keeping for some emergency equipment was lacking. We were advised that visual checks of the oxygen cylinders and defibrillator were routinely undertaken but not logged. During our assessment, staff advised they would begin to log these checks.

The leadership team advised that responsibility for undertaking environmental checks was held by the landlords of the property. The practice detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. There was a business continuity plan in place. 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. We observed fire exits were clear and fire safety equipment was easily available and regularly checked. Staff were aware of what to do in an emergency and where emergency medicines and equipment were stored. Allocated staff also knew how to safely manage spillages of bodily fluids. We observed that the clinical rooms and offices used by the GP practice were fit for use and there were room checks undertaken. All equipment had been checked and calibrated as required.

Leaders made sure there were enough qualified, skilled and experienced staff. We saw there were effective systems for clinical supervision of non-medical prescribers, which included regular auditing of their prescribing. However, we found there was no system in place to routinely check clinical staff maintained their annual registrations with the appropriate clinical body. We also found that 2 members of the nursing team had not received an appraisal for 2 years. In addition, evidence of effective oversight of staff training was not demonstrated. There was no staff training matrix that was maintained and up to date. It was therefore difficult for us to ascertain assurance that all staff training was complete and up to date. Following discussions with the leadership team, they advised they would start to record all training in a web-based platform that would act as a central hub for managing compliance and workforce information. Leaders advised that staff had not yet completed training on supporting people with a learning disability and autistic people. They advised training was scheduled for completion during December 2025. We reviewed employment records for staff employed within the last 12 months, under the current management team, and saw that safe recruitment practices had been followed.

The practice assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. Leaders ensured that facilities and equipment were safe, and that equipment was maintained according to manufacturers’ instructions. The practice had a designated infection, prevention and control (IPC) lead. Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks. The practice was able to demonstrate that it had an employee immunisation programme. Records of staff immunisation status were maintained.

The practice made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

Staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely. People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms. Staff felt confident managing the storage, administration and recording of medicines.

We found there was not an embedded system for the safe management of blank prescription forms. We were advised forms were only placed in one central printer and that logs of distributed forms were kept. However, when we visited the practice, we saw the logging of prescription forms had commenced the day before our site visit. Records showed the forms were distributed to 5 different printers. These logs were also incomplete and did not evidence that printers were emptied and prescription forms stored securely overnight.

Staff followed protocols to ensure they prescribed all medicines safely, and ensured people received all recommended medicines reviews and monitoring. Medicines were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines, vaccines, and controlled drugs. Waste medicines were recorded and disposed of appropriately including medicines returned by patients. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments.

The provider had effective systems to manage and respond to safety alerts and medicine recalls. Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring. For example, we reviewed patients prescribed a specific teratogenic medicine. Teratogenic medicines are medicines that can cause birth defects and therefore women of childbearing age should be informed of the risks and on effective contraception, whilst also receiving regular reviews. Our searches identified 6 patients taking one specific medicine and we reviewed records for 3 of these patients and found evidence the practice was reviewing and recalling these patients. 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. Our searches also reviewed patients taking specific medicines that require regular monitoring due to associated risks. We found that for one of these there were 38 patients prescribed the medicine and 3 potential patients who had not received regular monitoring as required. However, during our discussions and investigations with the practice we were assured that these patients were being recalled. For patients who repeatedly failed to attend appointments the practice advised they would seek further advice on how to manage their care. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.