The Kings Norton 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 remained the same.

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 service had a proactive and positive culture of safety, based on openness and complete honesty. The service had recently recruited a practice manager who had a proactive and positive culture of safety, based on openness and honesty. The leadership team listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. People felt supported to raise concerns and felt staff treated them with compassion and understanding.

Leaders encouraged staff to raise concerns when things went wrong. During staff meetings, the whole team discussed and learnt from incidents. 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. For example, leaders and staff demonstrated a positive approach to learning following a potential carbon monoxide incident at a branch site. Staff responded appropriately to the incident, escalating concerns promptly and seeking specialist support. The practice completed a detailed significant event analysis, reviewed the effectiveness of its response and business continuity arrangements, and identified learning to reduce the risk of recurrence. The practice identified and documented lessons learnt, developed an action plan with named responsibilities and timescales, and shared learning with staff through governance and team meetings. Improvement actions included reviewing carbon monoxide monitoring arrangements, updating emergency contact information and strengthening business continuity procedures.

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 were managed well in the service. Referrals were appropriately made within the timescales required by the NHS.

There was a documented approach to the management of test results, and this was coordinated in a timely manner. The service operated a team approach to managing test results rather than a named clinician or a buddy system. Under this model, all incoming lab results were added to a shared workflow and reviewed / actioned by the clinical team by the end of each working day. This collective practice model ensured robust clinical continuity, timely processing of all results, and eliminated single-point-of-failure risks associated with individual clinician schedules. Our review from clinical searches confirmed that laboratory results were processed 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.

The service demonstrated a commitment to safeguarding by working collaboratively with people and partner organisations to understand and promote safety while respecting individuals’ rights. Staff were proactive in recognising and reporting concerns promptly and appropriately. Comprehensive safeguarding policies for both adults and children were in place, well understood by staff, and supported by appropriate training. Staff consistently followed procedures in practice, as evidenced in reviewed cases. The service used a register to maintain oversight of vulnerable individuals and worked effectively with external agencies to manage and respond to safeguarding concerns.

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. There was an emergency deteriorating patient policy in place which helped reception staff to recognise a deteriorating patient in the reception area and understand what action to take. People 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. Contracts were in place to ensure the premises were maintained. Health and safety risk assessments and audits had been undertaken and risks identified had been addressed. 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. Staff worked together effectively to provide safe care that met people's individual needs.

During our initial site visit, the service was unable to provide complete recruitment records for some staff members. Leaders explained this was due to the sudden loss of access to recruitment records maintained on a password-protected computer that could not subsequently be accessed. Following this, the service reviewed its arrangements for storing personnel records and implemented a centralised electronic filing system that could be accessed by the wider leadership team. At our second site visit, we saw recruitment records were available and demonstrated that safe recruitment practices were being followed. The service had a recruitment policy and a separate Disclosure and Barring Service policy, and we found the necessary recruitment documentation was available for staff in line with these procedures.

There were a range of clinical and non-clinical roles within the service. We found training was up to date, learning needs and development of staff were managed appropriately, and staff were working within their agreed areas of competence.

Staff told us they could discuss clinical queries relating to prescribing, care and treatment planning with clinical leads who operated an open-door approach. This enabled staff to seek advice, reflect on their practice and identify opportunities to improve patient outcomes.

Appraisals were being completed regularly to support staff development. Staff reported feeling more supported in their roles and we saw evidence of career progression opportunities and access to additional qualifications and training.

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 service had a designated infection, prevention and control lead and all staff had had relevant training. They ensured staff had necessary knowledge and understanding by ensuring all staff completed annual training and discussing infection control issues regularly during team meetings and inductions.

Staff vaccination status was confirmed at recruitment, and risk assessments were in place for staff who were unable to confirm childhood vaccination status. All staff were encouraged to have annual vaccinations such as influenza.

Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened. Staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely. 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 followed protocols to ensure they prescribed all medicines safely, and ensured people received all recommended medicines reviews and monitoring.

Medicines were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines. The practice did not store controlled drugs but did stock emergency medicines such as Naloxone to support people who may have overdosed. 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. Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring. Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. Prescribing data reviewed as part of our assessment confirmed this. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.

As part of our assessment a Care Quality Commission (CQC) GP Specialist Advisor undertook searches of patient records on the service’s clinical system. Our clinical records reviewed the care of people prescribed high risk medicines that require monitoring such as Bisphosphonate (medicines that strengthen bones), Warfarin (a blood thinning drug) and Azathioprine (a drug which treats conditions that affect the immune system). We found all people had received the required monitoring and were appropriately coded on the clinical system. Coding on NHS records refers to the way healthcare information is recorded using standardised clinical codes instead of (or alongside) plain text. It helps doctors, nurses, and systems communicate clearly and consistently. Coding also helps in the audit process as it makes it easier to quickly search for, and action, people who may have been missed.

There was a process in place for recording and sharing medicine safety alerts. Safety alerts were discussed in clinical meetings. We reviewed patients who were prescribed Mirabegron (a drug used for the treatment of an overactive bladder). We identified a total of 64 patients prescribed these medicines and found 1 patient who was overdue blood pressure monitoring. The practice took immediate action to address this issue.

We reviewed a random sample of 5 out of 1183 medicine reviews completed in the past 3 months and found all had been appropriately completed.

As part of our assessment, we reviewed the processes in place for issuing controlled drugs. Controlled drugs are medicines that are regulated by the government. This is usually because they are at a higher risk of causing harm (such as dependence or misuse). Clinicians explained their systems and processes which included prescriptions not being issued on repeat; no more than 28 days of medicine prescribing; regular patient reviews; dedicated text messages to patients with information about the risks and monitoring required. There was a proactive approach to offering people the opportunity to reduce their medication.