Hall Green Surgery

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 good. At this assessment, the rating remains the same.

This service scored 75 (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. Managers encouraged staff to raise concerns when things went wrong. During staff meetings, the whole team discussed and learnt from clinical issues. Staff felt there was an open culture, and that safety was a top priority. They were able to give us examples of learning from significant events, and it was clear that there was a blame-free culture. The provider had processes for staff to report incidents, near misses and safety events. 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 practice worked with people and healthcare partners to establish and maintain safe 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. There were systems in place for processing information relating to new patients. The service worked with other providers to deliver shared care and when patients moved between services. Referrals and test results were managed in a timely way. The practice had an out of office function on electronic records system, so that if a GP was on annual leave, test results were directed elsewhere, meaning that patients faced no delays in receiving their results and onward care and treatment.

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.

Systems, processes and procedures were in place relating to safeguarding matters and concerns. Policies and procedures were reviewed and up to date and were aligned with other local safeguarding teams. Staff were aware of how to identify, report, and take action on safeguarding concerns.

Safeguarding alerts were added to the clinical record system when relevant, ensuring that all team members were aware of ongoing concerns and could act accordingly. The service had a designated clinical and administration lead for safeguarding adults and children at risk, and staff were aware of this. Partners and staff were trained to appropriate levels for their role. Safeguarding meetings were conducted every 3 months.

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.

The practice encouraged patients to attend for health screening. The practice told us parents of children who had not attended for childhood immunisations and people who had not attended for cancer screening, were followed up and further encouraged to attend. The practice opened for extended hours such as evenings and weekends to accommodate this.

Systems were in place for checking and monitoring emergency equipment and medicines. The practice kept recommended emergency medicines and equipment, including oxygen, and a defibrillator. All staff had been trained in basic life support. Staff could recognise a deteriorating person and knew the action to take.

The practice detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Health and safety risk assessments and audits had been undertaken and risks identified had been addressed. A comprehensive business continuity plan was in place to support any major service disruptions, such as IT failures. The business continuity plan was monitored and reviewed. There was also a business plan which included maintaining and improving the premises to ensure they were fit for purpose.

Records showed fire alarms were routinely tested, and the practice had appointed their own fire marshals to direct patients and staff in the event of a fire. Staff completed fire safety training and there were regular fire drills. Electrical equipment had been calibrated and tested. Safety alerts relating to equipment were shared with the relevant staff and acted on. We observed that the practice was accessible for all people and included space for wheelchairs and prams.

The practice made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. Staff received appropriate training and told us they were supported to progress within the team.

There were a range of clinical and non-clinical roles within the practice. We found training was up to date, learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence.

Safe recruitment practices were followed. We reviewed a sample of recruitment records which demonstrated that robust recruitment processes were followed, and all required documentation was consistently maintained.

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.

The practice had a designated infection, prevention and control lead and all staff had relevant training. Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks. Clinical waste procedures were in place. Staff had a complete record of staff eligible for immunisations, in line with national guidance.

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 received regular training, were competency assessed on medicines optimisation, and felt confident managing the storage, administration and recording of medicines.

Staff managed prescription stationery appropriately and securely. 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. 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. 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.