Churchfields 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 assessment, we rated this key question as good. At this assessment, the rating remains the same.

This service scored 72 (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. The practice had robust processes in place for staff to report incidents, near misses and safety events. These were investigated thoroughly, and learning was shared during regular team meetings. Managers encouraged staff to raise concerns when things went wrong. Staff felt there was an open culture, and that safety was a top priority.

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 such as the summarising of new patient notes. Referrals and test results were managed in a timely manner. The practice had an on call administrative GP who supported the clinical and administrative team and ensured all bloods and documents were actioned for clinicians who were not in that day.

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 practice shared concerns quickly and appropriately. Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. Flowcharts were available to staff to support them with reporting safeguarding concerns and helped them manage the safeguarding information coming into the practice. The practice maintained and a list of vulnerable people that was regularly reviewed and updated. Vulnerable people were coded on the system and had alerts added to their records including household contacts. The practice responded to and acted upon correspondence such as regular ae attendances. The practice had regular clinical and multidisciplinary meetings to discuss safeguarding concerns.

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 had a policy in place to inform staff of what to do in an emergency. Staff were also informed of this during their induction. Staff could recognise a deteriorating patient and knew of 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. Portable appliance testing and calibrations were up to date. Systems were in place to check safety equipment including fire alarms, emergency lighting and panic buttons, to ensure they remained in good working order. Fire evacuation drills were completed regularly. Control of Substances Hazardous to Health (COSHH) risk assessments were in place and all cleaning products and equipment were stored appropriately. Staff had been provided with training in health and safety related topics such as fire safety. During our site visit, we found the premises were well maintained. We received no concerns about the health and safety of the practice.

The practice 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. The practice monitored staffing levels and workforce capacity in response to service demand. We found training was up to date and staff were working within their agreed areas of competence. Safe recruitment practices were followed. The practice ensured staff employed through the primary care network (PCN) were suitably experienced, competent and able to carry out their roles. Leaders were involved in the interviews and worked closely with the PCN to ensure the staff employed were appropriate for the role. Learning needs and development of staff was managed appropriately. Staff received regular appraisals that included a development plan. Leaders supported staff to be upskilled, and we saw evidence of various staff taking on extra responsibilities and progressing into different roles throughout the practice. For example, both the practice manager and deputy practice manager started out in receptionist roles and nurses within the practice were supported to undertake training in chronic disease management such as diabetes.

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 (IPC) lead and all staff had completed relevant training. Regular IPC audits were completed to identify potential risks, and we saw evidence that they took appropriate action where required. Cleaning schedules were in place and followed. Clinical rooms had adequate provision of personal protective equipment (PPE) and handwashing facilities.

As part of our assessment, a series of remote patient clinical record searches were undertaken by a CQC GP specialist advisor. This included a review of the management of patients on medicines that required monitoring. We found that not all systems and processes worked effectively as not all medication reviews and monitoring were completed in line with best practice.

Our review of Methotrexate (an immune suppressant drug) identified 61 patients on this medication. 5 of these patients had potentially not received appropriate monitoring in the last 6 months. We reviewed all 5 records and found all patients had received the required blood tests. However, for one patient there was no evidence that the prescriber checked monitoring was up to date prior to issuing the prescription. For another patient, the shared care agreement was not saved to the patient’s file. Shared care agreements should be in place and easily accessible.

Our review of ACE inhibitor or Angiotensin II receptor blockers (used to treat high blood pressure, heart failure and chronic disease) identified 1,355 patients on this medication. 8 of these patients had potentially not had the required monitoring. We reviewed 5 of these records and found 2 of these patients had been seen several times by clinicians before eventually being recalled for monitoring. We saw evidence of the practice sending several messages to recall patients but the process of how to escalate this when a patient does not respond was not clear and did not reflect their policy.

We discussed our findings with the practice, and they took immediate action to follow up on the gaps identified.

Staff managed prescription stationery appropriately and securely. 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.