The Eaglescliffe Medical 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 that people were protected from abuse and avoidable harm.

At our last assessment, we rated this key question as good. At this assessment, the rating has remained as good.

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.

The service 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. 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. 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 held “lunch and learn” sessions, normally on a weekly basis, in which areas of learning could be focused on, such as research, GP training, and digital updates.

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.

We saw evidence of improvements that had been made to the referral process, such as the automation of certain processes to reduce the risk of human error. Feedback from people was positive in this area, with them describing timely and effective referrals to other services. The practice had a policy in place to manage the processing of clinical correspondence from other services. We saw evidence that tasks received from other services were actioned 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, who were appropriately trained in safeguarding procedures. There was a designated safeguarding lead, staff were aware of who this person was and how to contact them. The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations.

The service 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.

Emergency equipment was available and maintained. 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

As part of the practice website, there was a news section which included important clinical updates for patients. For example, recent guidance on weight loss injections and oral contraception.

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

During the assessment, we found that 2 emergency pull-cords in bathrooms were not in a position that could be pulled from the floor in the event of a fall. We notified practice leaders of this on the day of the assessment, and immediate action was taken by leaders to resolve this. We saw that documentation detailing the contents of an emergency medicine bag was not always accurate. This was discussed with leaders following our assessment. A policy was updated to include regular checks of the contents of the kit following our assessment.

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 comprehensive business continuity plan in place which was monitored and reviewed. The practice had an accessible toilet. The practice was visibly clean and tidy.

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.

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 saw evidence of regular staff appraisals that had been conducted and documented. We saw evidence of regular supervision and consultation audits of GP registrars working at the practice.

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 practice had a designated infection, prevention and control lead and all staff had had relevant training. Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks. We saw that the practice was clean and tidy, with well-maintained furnishings.

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

Medicines were stored securely and at appropriate temperatures. Staff regularly checked the expiry dates for all medicines, including emergency medicines and vaccines. Staff checked stock of emergency medicines. There was a printed document in place which listed the contents of the emergency medicine box, we saw that this list included a medicine which had previously been removed from the box and therefore did not reflect the contents on the day of the inspection. This was discussed with leaders following our assessment. A policy was updated to include regular checks of the contents of the kit following our assessment, and the medicine that was no longer stocked was removed from the list of contents. 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.

From our review of clinical records, we saw that medicines reviews did not always include a review of all of the patients medicines. There had been 1318 medicines reviews completed by staff the practice within the last 3 months. From our review of clinical records, we saw 3 medicines reviews that did not include the expected standard of documentation.

We saw evidence of information sharing when it came to medicines updates. We saw evidence of leaders reviewing prescribing data and analysing this against local and national averages.