Russell Street Group 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.

We assessed 7 quality statements from this key question. We found that the practice had a positive learning culture where people could raise concerns. The provider took appropriate steps to investigate incidents and ensure people were protected and kept safe.

The practice had carried out recent and appropriate health and safety and fire risk assessments. The facilities and equipment met the needs of people, were clean and well-maintained.

We found that there was an effective system in place for the storage, monitoring and allocation of blank prescription pads. A training log was in place to monitor staff training; however, this system was not used effectively. The log indicated a large amount of mandatory training was missing. However, the practice was able to provide evidence that staff has completed the required training. We found that the system intended to monitor staff training was not being operated as designed to assure leaders that all staff training was up to date.

The provider noted the feedback that the training log needs to be monitored and embedded and needs oversight to ensure accuracy.

At our last inspection in May 2024, we rated this key question as requires improvement, at this inspection the rating has improved to good.

This service scored 75 (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 positive culture of safety and listened to concerns and investigated and reported safety events. There were clear processes for staff to report incidents and near misses. Learning from incidents resulted in changes that improved care.

The operations manager managed non-clinical complaints, and the GP partners along with the practice manager led on clinical complaints. All complaints were handled according to practice’s complaints policy. Staff confirmed meetings were regularly conducted with the minutes recorded and shared. Feedback from PPG representative indicated that practice delivered high quality care that met their needs.

The service worked with people and healthcare partners to establish and maintain safe systems of care. The practice made sure there was continuity of care, including when people moved between different services. During the inspection, we reviewed patient correspondence, and our review confirmed that tasks and pathology results had been acted upon. Referrals to specialist services were documented in the patient record. Urgent referrals were monitored to ensure patients attended external appointments.

Clinicians could demonstrate oversight of the monitoring of people with long-term conditions and people’s medicine reviews.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

The practice worked with people to understand and manage risks by thinking holistically. Staff understood the role of involving people in making decisions about their care and treatment. Risks were identified and discussed with people and documented in the patient records, including those regarding do not attempt cardiovascular resuscitation (DNACPR) decisions.

Emergency equipment was available and maintained at all 3 sites. Staff had recent training and felt confident in recognising a deteriorating patient and knew of appropriate actions to take.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

At our last inspection in May 2024, we found gaps in the systems and processes to ensure safe recruitment of staff. During this inspection, we found the practice had reviewed their recruitment policies and had implemented procedures and processes to monitor this. We requested evidence of training for a sample of staff in several areas such as safeguarding and information governance. The training log indicated a large amount of training was not being undertaken which was noted as mandatory in the log. We also found staff recruitment files had some relevant employment documentation missing. The practice could not demonstrate that the training log and recruitment records for staff was managed appropriately. We found there was not a systematic approach to record documentation. However, the provider was responsive to our findings, and the practice was able to demonstrate that training has been completed. The pending records were shared with us promptly after the inspection.

We received some concerns regarding infection, prevention and control prior to this inspection. However, we found the service effectively assessed and managed the risk of infection. There was a designated infection, prevention and control (IPC) lead, and all staff who delivered care had undertaken relevant training. We observed that all 3 sites were clean and tidy and free from clutter. Cleaning logs were in place and appropriate systems were in place for the cleaning of equipment.

Risk assessments and audits had been completed, and actions taken to mitigate infection prevention and control risks, with the latest internal audit completed April 2025. We saw clinical waste was safely handled and disposed of in accordance with best practice IPC standards, however the storage of clinical waste needed a minor improvement which the practice acted upon.

We carried out remote searches of clinical records as part of our assessment. These included a review of records for patients prescribed high risk medicines to ensure that records were accurate and contained up to date reviews and monitoring. We found that in most cases the patients received appropriate reviews and monitoring. There had been significant improvement to the monitoring of patients prescribed high risk medicines. Our clinical searches showed there were still some concerns, such as the prescribing of gabapentinoids (medicines used to treat conditions such as epilepsy and nerve pain). We reviewed a sample of 5 patients and found that 3 had not received the required monitoring to ensure they were safe to continue taking the medicine. Other areas for improvement were identified during our assessment, and these results were shared with practice to follow up.

The provider had an effective system in place to receive and act on safety alerts. Patients had been advised of potential risks which meant they were able to make informed decisions about their care and treatment.

We found Patient Group Directions (PGDs are written instructions to supply or administer medicines to patients without a prescription or an instruction from a prescriber) were in good order. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines. There was programme of regular prescribing audit that focused on improving care and treatment.