Hattersley Group 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

The service had missed opportunities for learning and people felt their concerns were not listened to. The facilities and equipment met the needs of people, were clean and well-maintained. Some risks had not been identified on the risk register to ensure mitigation was in place. Some staff worked additional unpaid hours to complete tasks as there was insufficient trained and competent staff. Managers did not demonstrate staff had completed safeguarding, infection prevention and fire safety training. The oversight of the medicines management recall system for patients was not effective and patients were recalled following our assessment.

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.

Patients feedback and the national GP survey highlighted concerns with access to the practice. The provider had taken steps to improve this and had implemented a new triage system prior to our assessment. Learning and evaluation was under review at the time of our assessment.

The service did not always have a proactive and positive culture of safety based on openness and honesty. They did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice. People did not always feel supported to raise concerns. The provider had processes for staff to report incidents, near misses and safety events via a central team utilising the Patient Safety Incident Response Framework (PSIRF) and provided details of action reviews undertaken. There was a system to record and investigate complaints and the provider shared details of complaints and incidents where actions had been identified and training completed. However, there were missed opportunities for learning from incidents and complaints, staff gave examples of concerns raised and no action had been taken to address them and managers did not always encourage staff to raise concerns when things went wrong. For example, staff training had not been addressed. Representatives from the Patient Participation Group (PPG) felt the provider took concerns seriously and proactively made improvements to the service.

The service 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 service 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 and known to staff. The provider did not demonstrate staff were appropriately trained in safeguarding procedures. The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations. Staff told us the administration time to complete safeguarding duties were not always adequate and additional unpaid time was given to ensure tasks were completed.

The service did not always work well with people to understand and manage risks. They did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We saw evidence of processes for managing risks such as access to the service had improved. A new triage system had been introduced following feedback from patients. The national GP survey for those who responded positively to how easy it was to get through to someone at their GP practice on the phone was 24.7%. At the time of the assessment the new triage system had been in place for seven weeks. Staff and patients were positive about the improvement and the provider was monitoring and had plans to review the first few months.

The practice had a resuscitation and medical emergency policy in place. The practice was equipped to respond to medical emergencies including a range of emergency medicines, medical oxygen and a defibrillator. However, we found the risk assessment for emergency medicines was not followed.

We were not assured all staff could recognise a deteriorating patient and knew of action to take. No training records were provided to demonstrate staff had training for the deteriorating patient or sepsis. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

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

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. There was a business continuity plan in place which was monitored and reviewed.

The service did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

There were a range of clinical and non-clinical roles within the practice. We found training was not up to date. Safe recruitment practices were followed. The provider did not demonstrate the staffing model used was appropriate for the activity load of the practice. Some staff were working additional unpaid hours to support the practice and ensure tasks were completed. Staff also told us there was no longer a medical lead or diabetes specialist nurse for the practice, leaving gaps in clinical oversight We raised this with the provider for review following our assessment.

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

The provider had a designated infection, prevention and control lead. The provider did not demonstrate all staff had had relevant training. Cleaning schedules were in place and followed. Audits were completed.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

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 managed prescription stationery appropriately and securely. However, protocols to ensure staff prescribed all medicines safely, were not always followed. 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 systems to manage and respond to safety alerts and medicine recalls. Staff did not always follow processes to ensure people prescribed medicines with specific risks received recommended monitoring. For example, our clinical searches identified some patients had not had the appropriate monitoring for direct oral anticoagulants. These medicines are used to prevent blood clots form forming. If unmonitored there is a risk of bleeding, which can be serious or fatal.

There was not a programme of regular clinical audits for prescribing that focused on improving care and treatment.