Holbrooks Health Team

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 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.

Patients 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. 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. During our assessment, staff gave examples of being involved in investigation and learning outcomes for future development.

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. We found the provider was up to date with summarising patient records. The service worked with other providers to deliver shared care when patients moved between services. During our assessment we reviewed the systems and processes for referrals and test results and found they 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, 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.

We found examples of non-clinical staff recognising safeguarding concerns and a clear process of escalation and support to individuals because of this awareness. The practice clinical system had safeguarding alerts to ensure vulnerable patients were managed appropriately and we found safeguarding meetings to be clear and evidenced actions taken. The practice had monthly safeguarding meetings with leads and health visitors.

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 what action to take. 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.

Health and safety risk assessments and audits had been undertaken and risks identified had been addressed. Whilst the building was dated, the practice took necessary actions to keep the premises safe to deliver effective care. There was a business continuity plan in place which was monitored and reviewed.

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. During our assessment we reviewed five staff files and found safe recruitment practices were followed and maintained, however record keeping was inconsistent between each staff members file, the provider acknowledged this and was working towards an effective system for document management.

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. Risk assessments and audits were completed, and actions taken to mitigate risks. However, whilst the practice looked visibly clean there were no cleaning schedules or systems in place to provide assurance that cleaning standards were consistently maintained. The provider took immediate action and evidenced cleaning schedules and polices that would be in place going forward.

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.

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 regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines. 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. The provider had effective systems to manage and respond to safety alerts and medicine recalls.

As part of our assessment, remote clinical searches were conducted by a GP Specialist Advisor. Our clinical searches indicated that staff did not always follow established processes to ensure people prescribed medicines with specific risks received the recommended monitoring.

For example, our clinical searches found 180 patients prescribed ACE inhibitors or Angiotensin II receptor blockers (medicines to help lower blood pressure) had potentially not had the required monitoring. Upon discussion with the practice, we found that 50 of these patients were on shared care agreements and relevant documentation was subsequently inputted onto the practice system, the practice evidenced that the remaining 130 patients had been booked for a review. The practice demonstrated repeated attempts to recall patients for reviews, however they did not have a policy to shorten the script for patients to encourage a review for compliance. During the assessment process the practice established new systems and polices for staff and patients to ensure compliance. They also provided evidence of contact with, and scheduled reviews for, patients who required ongoing monitoring. However, these actions were newly implemented and there was insufficient evidence at the time of inspection to demonstrate they were fully effective or consistently embedded.