The Northolme 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 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.

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.

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.

The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The main and branch sites operated by the service were kept in a good overall structural condition. However, health and safety processes linked to the safe operation of the practice needed action and improvement. We found that the fire risk assessment and the legionella risk assessment were both out of date, having been undertaken in 2022 and 2016 respectively. In mitigation of this we saw that there were actions in place to control risks associated with fire and water safety which included the servicing of fire extinguishers, the testing and maintenance of fire alarms, and the checking of water temperatures. We also found that testing of portable electrical appliances had not been undertaken since 2022. Some general health and safety oversight checks were made on a regular basis; however, there was no evidence of comprehensive health and safety risk assessments for activities such as lone working, working at height and manual handling. Following our visit to the service they have provided evidence to show that the required health and safety assessments had been booked, and that the health and safety risk assessments had been completed.

The service had a business continuity plan which was updated regularly and outlined how the service should continue to operate in the event of a disruption.

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. However, there was only limited assurance that all staff had received required mandatory training, and that staff vaccination and immunisation status was in line with national guidance.

The service employed a range of clinical and non-clinical roles, which included GPs, advanced care practitioners, nurses, and other healthcare staff. Overall, we found that most staff were up to date with their training which the service had deemed mandatory, and that they operated within their agreed areas of competence. However, it was noted that records of training attainment were not initially up to date.

We saw that the service had clinical supervision processes in place to support identified staff members such as non-medical prescribers. We saw that some assessments of consultations and prescribing had taken place, and staff had the ability to ask advice and discuss clinical cases with more experienced staff members. However, this was informal, and we did not have assurance that this was applied consistently. When we raised this with a GP partner they told us they would examine formalising their approach to this area of work.

The provider could not demonstrate that staff working at the practice had received the required vaccinations and immunisations in line with national guidance. Personnel records that we checked were not complete for all members of staff. The service told us that they had done some work with staff to assess vaccination and immunisation status, but that this had not been completed. The service also later informed us that they were to introduce a more robust system to assess and confirm staff vaccination and immunisation status.

The service followed safe recruitment procedures when employing staff, which was in line with national legislation. This included identity checks, obtaining of professional references and a criminal records check.

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

The service had cleaning schedules available, which outlined how staff and contractors should clean the building and its equipment. The service demonstrated how these were monitored for completion to maintain oversight of cleaning arrangements. During our onsite visits to the main and branch sites we saw that the premises and equipment were maintained in a clean and hygienic condition. The service had appointed a lead staff member who managed infection prevention and control, and who conducted regular checks and audits to ensure compliance. When identified, the service took action to mitigate and rectify any identified risks and concerns. When we assessed staff records, we saw that mandatory infection prevention and control training had been undertaken by the majority of staff.

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