Stephenson Park Health Group

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 safe care and treatment.

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.

Staff told us of an open and honest working environment, where they were supported by leadership, felt they were able to raise concerns and that their views were listened to and acted upon. For example, when immunisations received by a receptionist were not immediately placed in the fridge, resulting in a failure of the cold chain process, all staff were informed of the cold chain policy, and the importance of following it was reinforced. As a result, a fridge was installed in the reception area at Forrest Hall, ensuring that vaccines could be safely stored and the cold chain maintained if access to the nurses' fridge was not immediately possible.

Representatives from the Patient Participation Group (PPG) felt the provider took concerns seriously and proactively made improvements to the service. One suggestion made by the PPG was to improve appointment accessibility, as patients previously found it difficult to book appointments. In response, the practice implemented changes that have made the booking process easier.

Staff understood how to raise concerns and report incidents. There was a system to record and investigate complaints. Lessons learned from complaints led to service improvements, such as changes to the appointment system and the introduction of a total triage system, making appointments more accessible.

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. Referrals and test results were managed in a timely way.

The practice maintained effective oversight of triage by assigning 1 duty doctor and 1 clinician each day to manage urgent patient issues during surgery hours.

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.

Staff were able to tell us who the safeguarding lead was in the practice and how to raise concerns. They told us they received training in both safeguarding adults and children and had a clear understanding of their safeguarding responsibilities for reporting concerns.

Safeguarding policies were in place and known to staff; however, at the time of the assessment, the safeguarding leads named in the policy did not reflect the true safeguarding leads at each site. In response to this feedback, leaders took immediate action.

The practice had a chaperone policy in place, ensuring that chaperones were available to provide comfort and to help mitigate risk for both patients and staff.

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

Disclosure and Barring Service (DBS) for staff were undertaken when required.

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.

We saw examples of minuted multidisciplinary team (MDT) meetings involving health care professionals where patients were discussed to help manage risks associated with them.

Emergency equipment was available and maintained. Staff could recognise a deteriorating patient and were aware of what action to take in a medical emergency. Patients were advised on risks related to their condition and actions to take if their condition deteriorated. Staff received annual training in cardiopulmonary resuscitation (CPR) and management of anaphylaxis.

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.

However, there were no emergency pull cords in the disabled toilets at the Forrest Hall and Garden Park sites.

Some administration staff were found to be overdue for their appraisals, with no appraisal having taken place since January 2024 in some cases. Additionally, the practice manager had not received an appraisal for several years. The practice informed us that a plan to address this had been in place since summer 2023.

There was no formal process for assessing the competence of non-medical prescribers. Clinical supervision was only conducted for trainees, registrars, and new staff. The practice informed us that, while an ad-hoc support system existed, such as daily on-call support for non-medical prescribers and opportunities to discuss cases during monthly clinical team meetings, there was no structured approach currently in place. Following the assessment, the practice told us they planned to implement a formal 6 monthly clinical audit, carried out by a GP. This would include maintaining documented records of the reviews undertaken.

Additionally, administration staff had not been asked to provide their vaccination status. According to the Green Book, a guide published by the UK Department of Health and Social Care on immunisation practices, clinical and non-clinical staff in healthcare settings, including receptionists, should be up to date with routine immunisations, including tetanus, diphtheria, polio, and Measles, Mumps, and Rubella (MMR). Following the assessment, the practice informed us that steps had been taken to begin collecting vaccination status information from staff.

Furthermore, 42% of staff who responded to the staff questionnaire felt that the practice would benefit from increased staffing levels.We were informed after the assessment, the practice was actively recruiting, including advertising for an additional GP role.

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

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 (IPC) lead, and all staff had received relevant training. Risk assessments and audits were completed, and actions taken to mitigate identified risks. However, due to recent staff changes, the IPC lead at Forrest Hall was unaware of their designation as the lead, as a result of miscommunication.

Cleaning schedules were in place and followed however, the cleaning schedule for the White Swan site, managed by North Tyneside Council, was unavailable, so we could not be assured it had been completed.

While the practice had systems in place to support the management of long-term conditions, including a dedicated medications team, the use of remote monitoring processes, and the delivery of “Year of Care” planning, we identified instances during our clinical review where these systems were not always applied effectively. A review of clinical records showed:

There was a lack of oversight of patient’s currently prescribed a direct oral anticoagulant (DOAC), with 44.4% not having the correct monitoring in the past year and 10.4% never monitored.

The practice had a system in place for responding to safety alerts; however, it was not always effective in identifying and acting on legacy alerts. For example, a search identified 24 patients prescribed both omeprazole and clopidogrel, a combination that should be avoided.

We found 4 patients who were being prescribed metformin despite having reduced kidney function (eGFR

There was no recorded evidence of medication reviews for gabapentinoid prescribing and polypharmacy, although the practice stated these reviews had been completed but not coded correctly. However, during the assessment, the practice demonstrated that reviews had been conducted on a small random sample of patients.

A review of 3 patients potentially having a missed diagnosis of diabetes revealed issues with adherence to national guidelines, specifically regarding interval testing after a raised HbA1c (blood glucose level) above 47. The practice told us this represented a small number in the context of their patient list size and that they routinely ran searches to identify and monitor such cases.

However, the monitoring of angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARB), which are used to treat heart failure and high blood pressure, was well managed. Systems were in place to monitor vaccines, emergency equipment and medicines. Staff had the appropriate authorisations to administer medicines under Patient Group Directions (PGD). Medical oxygen and a defibrillator were available, with systems in place to ensure regular checks.

Leaders confirmed prompt action was taken in response to the findings mentioned above, and processes were implemented to address these issues.