Lower Gornal 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.

The service had established systems in place to support the delivery of safe care, though several areas required further strengthening. Staff demonstrated an awareness of procedures for raising concerns, and managers took responsibility for investigating incidents. However, the learning from significant events and complaints was not consistently shared across the wider team, limiting opportunities for organisational improvement.

Recruitment processes were in place, but aspects such as staff immunisation protocols needed further strengthening. In addition, gaps were identified in staff training requirements and there was insufficient oversight of non-medical prescribers.

This service scored 47 (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 culture of safety, based on openness and honesty. Safety events were investigated and reported appropriately. Staff understood the procedures for escalating significant events and submitting complaints. The provider had a duty of candour policy in place, and when incidents occurred, staff offered apologies and support to those affected. However, feedback from staff suggested that learning outcomes from significant events and complaints were not consistently shared across the team. Few staff could recall occasions where learning had been effectively communicated. In addition, meeting minutes indicated that complaints were not regularly included as a standard agenda item. The practice also lacked systems to identify patterns or trends in complaints and incidents, limiting its ability to assess whether any actions taken had led to measurable improvement.

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 collaborated effectively with healthcare partners to develop a shared understanding of what constituted safe care and how to achieve it. Safeguarding procedures were established across the practice, and staff demonstrated awareness of how to take appropriate action when concerns arose. Policies relating to safeguarding were in place and familiar to staff, who were able to identify the designated safeguarding lead. The practice informed us that staff were scheduled to attend the IRIS (Identification and Referral to Improve Safety) training on domestic violence and abuse next month.

Multidisciplinary safeguarding meetings were held every three months, coordinated by the Advanced Nurse Practitioner (ANP) alongside a health visitor, school nurse, and midwife. The safeguarding lead was not in attendance at these meetings, and their child safeguarding training had lapsed and was due for renewal to ensure continued alignment with safeguarding standards. At the time of review, we did not see documented evidence of investigations into safeguarding concerns or of shared learning from previous incidents.

Our review of the practice’s clinical system found that patient records contained safeguarding flags; however, this was inconsistent. For example, there were no flags to identify vulnerable adults or individuals residing in the same household. Additionally, some historical alerts remained active without reassessment, raising concerns about the accuracy and relevance of existing flags.

We addressed these findings with the provider who agreed to strengthen the safeguarding registers to ensure all patients at risk of harm or abuse are appropriately identified and not overlooked.

The service worked with people to understand and manage risks, however this needed strengthening so that care met people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Emergency equipment was available and maintained. However, we observed that domestic surface wipes had expired in 2023, and there was no documented assurance that their suitability for use on equipment had previously been reviewed in accordance with COSHH requirements

Staff could recognise a deteriorating patient and knew of action to take. In addition, staff were aware of the location of the emergency medicines and medical equipment, for example oxygen and the Automated External Defibrillator (AED).

Patients were provided with advice regarding risks related to their condition and informed about actions to take should their health deteriorate. Staff training records were maintained, though we noted that some clinicians had outstanding updates in areas such as sepsis, anaphylaxis, and first aid. Staff demonstrated understanding of emergency protocols and were able to activate the integrated panic alarm system when required.

Systems were in place to support individuals experiencing communication barriers in accessing care; however, we were informed that the hearing loop had not been operational for the past two years and had yet to be replaced. Clinicians had not yet completed training in learning disability and autism, though attendance had been scheduled for the following month.

Following the inspection, the hearing loop was formally reported to NHS Property Services for further action.

The premises were managed by NHS Property Services. Staff told us, in some cases, the absence of designated disabled parking could present a physical barrier; however, they approached this by offering support to patients by facilitating parking outside the building or waiting in the nearby community service waiting area when additional assistance was needed. A wheelchair was available for use if required.

Observations confirmed that the premises were clean, however, in one clinic room, signs of wear and tear were noted, including a ripped chair, peeling and chipped paint on the wall, and the absence of an adjustable-height couch. In the administrative office, a non-functioning air conditioning unit was identified, which may pose a health and safety concern during periods of warmer weather. The practice shared that the matter had been escalated to NHS Property Services, though resolution was pending due to ongoing discussions regarding replacement costs. One consultation room lacked both a patient couch and a sink; assurances were sought to confirm that this space was designated for administrative use rather than clinical activity. Following the inspection, the decoration concerns were formally reported to NHS Property Services for further action.

Risk assessments for the premises had been completed, and the provider advised that plans were in place to modernise the site and expand room capacity. Clear signage was present throughout the building to support safe evacuation procedures in the event of an emergency.

Health and safety protocols, including fire safety measures, were in place across the practice. Staff had received training in health and safety topics such as fire procedures, infection control, and manual handling. However, it was noted that not all staff consistently signed into the building, which posed a potential risk in the event of a fire or emergency evacuation.

The practice maintained a business continuity plan that provided structured guidance in the event of significant service disruptions, including IT system failures.

The service maintained sufficient numbers of qualified, skilled, and experienced staff. However, consistent support, supervision, and oversight were not always evident for clinicians.

For example, the practice was unable to demonstrate how it assured the competence of staff working in advanced clinical roles, including locums. At the time of inspection, formal processes for advanced nurse practitioners relating to prescribing competency were in early stages of implementation. Structured mechanisms such as regular prescribing reviews, clinical supervision, and documentation of competencies were not yet fully established. Although nursing meetings were held and led by the Advanced Nurse Practitioner (ANP), there were limited systems in place to monitor and confirm nurses’ ability to practice at an advanced level.

During the inspection, we observed that a locum ANP had completed pathology reports; however, the practice was unable to verify their competency in this area. Leadership acknowledged this feedback and recognised the need for continued development and improvement in this aspect of clinical governance.

Whilst a staff training programme was in place, data provided on mandatory clinical training did not confirm whether some staff were up to date. Training gaps included areas such as safeguarding, equality and diversity, infection control, and mental capacity. Some staff indicated that they lacked sufficient protected time to complete their training requirements.

All staff, both clinical and non-clinical, had received an appraisal. While some appraisals had lapsed at the time of inspection, they had been scheduled for completion. It was noted that completed appraisals had not always been thoroughly documented by management.

Recruitment procedures complied with relevant regulations, but immunisation records for staff were not consistently available. The practice manager acknowledged this gap and was committed to addressing it to ensure the safety of both staff and patients.

The service had effective measures in place to assess and manage the risk of infection and shared information with relevant external agencies as required. Infection prevention and control (IPC) policies were established, accessible to staff, and overseen by a designated IPC lead. Most staff had completed the necessary training related to IPC protocols.

Cleaning schedules were in place and adhered to. An IPC audit conducted in October 2024 showed an overall compliance score of 98%. However, during our site visit, we observed peeling and chipped paint in one clinic room and a ripped chair, which could compromise infection control standards. Additionally, the practice informed us that a desk was routinely removed from a clinical room prior to conducting minor surgical procedures, suggesting that the room may not have been appropriately configured or fully suitable for minor surgery use. Additionally, we found no evidence of a documented risk assessment to confirm that health and safety provisions or infection control protocols had been adequately considered or reviewed to ensure a safe environment for patients and staff. At the time of our inspection, the practice informed us that they were awaiting formal approval to expand the number of clinical rooms. This proposed development formed part of their broader strategy to increase capacity and strengthen service delivery.

Staff checked the stock levels and expiry dates for all medicines, including emergency medicines, vaccines, and controlled drugs. Staff stored oxygen safely. Fridge temperatures were checked regularly, and appeared to be functioning; however, scheduled servicing had not been consistently completed since 2023. We identified gaps in the availability of five emergency medicines and noted the absence of risk assessments explaining the rationale for not holding them.

Clinical staff described the practice’s processes for monitoring patient health, including the management of high-risk medicines. Staff demonstrated awareness of current practices and guidance. While GPs were accessible for case discussions, there was no formal system in place to assess the competence of non-medical prescribers. A recent review had been completed for one non-medical prescriber, but an overarching, structured assessment process had yet to be established.

Prescribing policies and procedures were in place. However, clinical meetings aimed at reviewing patient cases, sharing knowledge, and identifying improvements were not held consistently. These meetings were largely led by the nursing team, with limited GP involvement. GPs acknowledged this and recognised it as an area for development and oversight.

Remote clinical searches conducted by our GP specialist advisor indicated that the practice was meeting certain prescribing standards. However, some areas were identified where further improvement was required.

As part of our clinical searches, we looked at patients who were on ACE inhibitors or Angiotensin II receptor blockers who had received the required monitoring. This is medicine used to treat blood pressure abnormalities. We identified that 41 patients (3%) of patients on this medicine potentially required monitoring. Of the 5 records sampled, 4 people were overdue monitoring. Additionally, we found that some patient consultations were inconsistent and lacked objective findings (for example, blood pressure) or there was no commentary, and a code added.

While systems were in place to manage and respond to safety alerts, our review identified one alert concerning a medicine known to increase the risk of myopathy when combined with other medications. We found no evidence of this alert being documented or discussed with patients in the clinical records. Antibiotic prescribing was in line with the local average in 5 of the 6 indicators and showed negative variation in one indicator.

Nursing staff did not always have the appropriate authorisations to administer medicines (Patient Group Directions) as we found 5 PGD’s which were not appropriately signed, dated and authorised.This issue was discussed during the on-site visit, and immediate action was taken to rectify the documentation and ensure compliance with relevant protocols.

We identified that the management of blank prescriptions on site required strengthening, as there had been no documented review, audit, or check of unaccounted prescriptions and prescription pads for several years. Following the inspection, the provider sent assurance that this matter had been actioned.