Haden Vale 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 changed to Requires Improvement.

The service was in breach of legal regulation in relation to:

• High risk medicines were not being monitored appropriately to ensure people received the appropriate care.
• The provider had no process in place to ensure that staff providing care and treatment to patients had the skills and experience to do so safely.
• The provider was unable to demonstrate they complied with the relevant safety alerts issued by the Medicines and Healthcare products Regulatory Agency (MHRA).
• The provider was unable to demonstrate that learning from incidents and significant events was shared with the wider team to mitigate future risks.

Systems were in place to protect individuals from abuse and avoidable harm; we found safeguarding procedures and those at risk were regularly reviewed and their safety was clearly prioritised across the service.

Health and safety procedures were in place, and the premises were appropriately maintained.

We found medicines optimisation and the actioning of safety alerts required strengthening to ensure people’s safety was integral to the care and treatment they received.

We found safety incidents were investigated, however the process for sharing learning required strengthened to identify shortfalls and prevent recurrence and mitigate any future risks.

We identified concerns in the clinical supervision of some staff with no clinical oversight of staff carrying out medicine reviews to ensure they had the appropriate training and qualifications to do their role effectively.

Pre-employment checks were completed, and staff received safeguarding training relevant to their roles, alongside regular appraisals and ongoing training in other areas to maintain high standards.

This service scored 62 (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.

Managers encouraged staff to raise concerns when things went wrong. We found meetings with the whole practice team were not held on a regular basis and we had no assurances that the learning was discussed and shared with all departments. Staff told us learning was shared on an individual basis with the person concerned, but there was no structured process in place. 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. The practice had a significant events policy and a reporting form was in place, which was accessible to all staff members. We found on speaking with some staff they were unaware a reporting form was available and would report directly to the management team any concerns they identified.

The practice had a system in place to record and investigate complaints. The practice had a complaints procedure in place. We reviewed a random sample of complaints and found the provider had responded in a timely manner and had offered apologies to people. Lessons were learnt from individual complaints and shared with the practice team to improve the quality of care.

Information reviewed demonstrated that people had opportunities to provide feedback and they knew how to make a complaint. Feedback and information were available in the practice and on their website. The outcome of the GP National Patient survey showed people had enough time during their consultation, they felt involved in decisions about their care and treatment and had confidence and trust in the healthcare professional they saw or spoke to.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. 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.

Effective systems were in place for processing information relating to new people including the summarising of new records. We found clinicians made appropriate and timely referrals in line with protocols and up to date evidence-based guidance. This was supported by a system in place to ensure all patient information including laboratory test results and referrals were reviewed and actioned in a timely manner.

The provider told us that there were processes in place that was monitored and managed to keep people safe. For example, the provider was part of the Primary Care Network (PCN) and attended regular meetings with other agencies across the locality to share and discuss information relating to patient care and treatment, for example, people on the practice palliative care register.

There were a range of structured meetings in place. These included clinical meetings, safeguarding and practice team meetings.

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. The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations.

There were processes in place to follow up children and young people who were not brought to their appointments with the provider and for secondary care appointments and safeguarding meetings were held on a regular basis to review people at risk. Community teams were invited, however the practice told us they struggled to get people to attend, however they ensured information was shared appropriately for the care of people with safeguarding and vulnerable concerns.

There was a safeguarding lead for children and adults and all staff were aware of who to speak to if they identified a safeguarding concern. 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.

There was a policy in place for the renewal of DBS checks. Records we examined showed that all staff had a DBS check in place. DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable.

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.

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

Leaders told us that they worked with services locally to understand and manage risks. The practice also had registers in place to support those patients who were vulnerable or who had mobility or communication needs.

All staff were trained in basic life support and receptionists were aware of actions to take if they encountered a deteriorating or acutely unwell patient and had been given guidance on identifying such patients.

The service 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 related assessments and procedures to manage health and safety were in place. This included fire safety. Staff had been provided with training in health and safety related topics such as fire safety, infection control and manual handling. Staff reported during discussions that they had no concerns regarding the arrangements in place to ensure health and safety.

There were policies and procedures in place for the management of health and safety. Fire safety policies were in place and staff were aware of how to access these. Fire marshals had undertaken additional training for the role. Systems were in place for the regular checks of fire alarms, extinguishers and fire evacuation procedures.

The practice had completed assessments in place for the control of hazardous substances. Evidence provided by the practice showed equipment was regularly calibrated and electrical items were Portable Appliance Testing (PAT) tested.

There was a business continuity plan in place which was monitored and reviewed. Reception and administration staff who handled calls to the practice and arranged appointments with the clinical team were aware of potential red flag symptoms. Staff knew when to notify a GP or other clinicians with concerns about a patient who may be acutely unwell and/or deteriorating.

During our site visit we found the premises were well maintained. The provider detected and controlled potential risks in the environment. They made sure equipment, facilities and technology supported the delivery of safe care. Regular checks were carried out on the premises, facilities and the equipment provided. Contracts were in place to ensure the premises were clean and well maintained. Clear signage around the building supported people and staff in the event of an emergency evacuation.

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

We found the practice had not ensured that staff working in clinical areas had received the appropriate training and monitoring to confirm they were competent in their role. For example, we found one of the nursing team was carrying out medicine reviews but had not completed formal training in prescribing. We were unable to gain assurances that the appropriate supervision was in place and staff were aware of clinical guidelines in relation to prescribing and the actioning of alerts on clinical records.

We were told of plans to increase the number of clinical staff available; an advanced nurse practitioner and salaried GP were due to start at the practice in August 2025.

The practice had recruitment policies in place and all staff had completed disclosure and barring checks. All newly employed staff had completed an induction to ensure they were competent in carrying out their role. We reviewed 4 personnel files and found appropriate checks such as previous employment record and proof of identity checks had been completed. Personnel folders were well organised and there was a systematic approach to ensure that personnel folders were managed appropriately. We found staff immunisation status records were in place.

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The practice had policies in place for infection, prevention and control which was accessible to staff and staff were aware of the action to take. For example, in the event of a sharps or contamination injury.

The practice had a designated infection, prevention and control lead and all staff had completed infection prevention and control training relevant to their role and staff were aware of the systems and processes to follow to ensure clinical specimens were handled safely.

A recent infection control audit had been completed and the practice had achieved 96%. A plan was in place and we found actions had been completed. However, we found the curtains in three of the consultation rooms had no date to demonstrate when they had been changed. Infection Control guidance states that curtains and blinds should be cleaned or changed every 6 months. We were unable to gain assurances that there was a procedure in place for regular decontamination of curtains. During the onsite assessment, dates were added to the curtains to show when they had been changed. Following the onsite assessment we received evidence to demonstrate that a risk assessment had been completed to ensure no risks had been identified with the curtains not being dated.

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.

As part of the assessment, we carried out remote clinical searches. We reviewed the number of people who had been prescribed methotrexate, a medicine that is used to treat inflammatory conditions. The search showed 25 people were on this medicine. We reviewed a random sample of 5 records and found a safety alert issued by the Medicines and Healthcare products Regulatory Agency (MHRA) in 2020 had not been acted on. The alert advised that the day of administration of methotrexate should be clearly documented for patients. This reduced the risk of inadvertent daily administration leading to toxicity. None of the 5 records we reviewed had been actioned with this alert. We also found medicines were not being linked to health conditions when we reviewed patient records. Following the onsite assessment, we received assurances that the clinical templates had been updated to ensure the appropriate actions were taken when prescribing this medicine. Further review of the clinical records showed alerts on records had not been acted on. For example, overdue monitoring and medicines that people required to support their health conditions. A second search showed the number of people who had been prescribed medicines to reduce the risk of blood clots forming called direct oral anticoagulants (DOACs). The search identified 173 people on these medicines. We reviewed 3 clinical records contraindications of DOACs being prescribed. Alerts were showing on the clinical records, but these had not been acted on. A review showed people had not had creatinine clearance levels calculated. A creatinine clearance test is used to check kidney function. A further review showed 39 patients over the age of 75 years on DOACs had not had the appropriate reviews in the last 6 months. Clinical guidelines require this to be done every 4 months. Following the onsite assessment, we received a detailed response from the clinical team to the findings of the clinical review. Evidence was provided of the actions that had been taken to review the patients on these medicines. We were assured that patients were being monitored and systems were being implemented to ensure alerts on clinical records were responded to in a timely manner. Further evidence was provided which demonstrated there had been an issue pathology results being received by the practice from the laboratories. This had impacted on some of the clinical findings we identified during the remote searches of the clinical system.

A search of the clinical system was completed to identify people on metformin, a medicine used to treat diabetes, with an eGFR of less than 30. eGFR is a measure to demonstrate how well a person’s kidneys are working. The search identified 1 person. We reviewed the clinical record and found the patient had been reviewed by a member of the clinical team who had no prescribing qualifications. We also found a MHRA alert issued in 2022 advising of the potential of decreased vitamin B12 levels for people on metformin had been actioned for this patient. Following the onsite assessment, we received evidence to demonstrate that a review had been completed by the clinical team to ensure all patients had been reviewed appropriately.

The provider was unable to demonstrate they had processes in place to ensure the systems to contact people about potential risks identified through safety alerts were effective. We carried out a search to identify the number of people on specific medicines to treat epilepsy and the potential to increase the risk of birth defects. We identified 5 people on this type of medicine. We reviewed 1 clinical record and found no evidence to demonstrate that the patient had been counselled before the medicines were commenced and provided with the appropriate contraception advice. Clinical alerts on the patient record had also not been actioned. Following the onsite assessment we received evidence to demonstrate a clinical review had taken place and actions had been taken to mitigate risks.

We were unable to gain assurances that staff were competency assessed as we found staff without prescribing qualifications were carrying out medicine reviews without the appropriate knowledge or competencies. Staff managed prescription stationery appropriately and securely. Medicines including controlled drugs 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. 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. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.