Eve Hill 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 to Outstanding.

This service scored 88 (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 strong proactive and positive culture of safety, based on openness and complete honesty. Leaders and staff actively encouraged the raising of concerns, and there was clear evidence that all safety issues were listened to, thoroughly investigated, and used as opportunities to drive meaningful improvement. Learning was consistently embedded into practice, with a clear focus on delivering sustained improvements in care and outcomes.

Robust and well-established systems were in place to report, investigate, and learn from incidents, near misses, and complaints. As a training practice, there was a clear organisational commitment to learning at every level. A comprehensive programme supported staff development, including departmental meetings, quality and safety meetings, and whole practice learning events. These meetings enabled multidisciplinary reflection on both clinical and non-clinical issues, fostering continuous professional development and service improvement.

The practice further demonstrated learning through the delivery of targeted educational events, featuring guest speakers. Topics included care navigation, health and wellbeing coaching, complex asthma management, and wound care, reflecting a proactive approach to workforce development.

The service consistently demonstrated openness and candour when things went wrong. Patients received timely and meaningful apologies alongside appropriate support. Significant Event Analysis (SEA) processes were comprehensive and well embedded, incorporating robust root cause analysis and supported by annual thematic reviews to identify trends and recurring issues. Over the previous 12 months, 40 SEAs had been completed and reviewed, demonstrating a high level of engagement with reflective practice and continuous improvement. We saw clear evidence of thorough investigation and detailed reporting of incidents. Staff were able to provide examples of learning from prescribing errors, palliative care, and information governance, demonstrating that learning was effectively translated into tangible improvements. For example, a prescription was amended but not formally issued to the patient, resulting in a delay. This incident was reviewed, appropriate action was taken, and key learning was reinforced with staff, around completing a final issue check. Other additional learning included that during a Gold Standards Framework (GSF) meeting, coding to identify palliative care patients was incomplete. This was reviewed and addressed, leading to the introduction of bi-monthly GSF audits to minimise the risk of missed coding and to improve the accuracy and completeness of the register.

Following a delay in a two-week wait referral, the practice also reviewed its processes and implemented monthly audits of outstanding tasks. These audits were actioned to identify tasks assigned to users who log in infrequently, as well as to highlight any staff members with backlogs, ensuring timely follow-up and improved workflow management.

Staff feedback strongly reinforced the positive safety culture. Staff described an open and psychologically safe working environment, consistently reporting confidence in raising concerns and contributing to improvements.

Complaints were managed effectively, with clear systems in place to ensure timely investigation and shared learning. Learning from complaints was actively disseminated and embedded across the practice and internal updates were used to reinforce key messages and promote organisational learning.

Representatives from the Patient Participation Group (PPG) reported that the practice listened to concerns and acted proactively to drive improvements. PPG members were invited to quality and safety meetings on a rolling basis, promoting transparency and shared ownership of service development and best practice.

Overall, quality, learning, and safety were deeply embedded within the practice’s governance framework. Staff at all levels felt supported and empowered to raise concerns, and leaders consistently promoted a culture of openness, reflection, and continuous 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.

Effective systems were in place for processing information relating to new people including the summarising of new records. The service worked with other providers to deliver shared care when patients moved between services.

A clear and robust referrals policy was in place, supported by comprehensive guidance to promote consistency and safety in referral processes. The practice had developed and delivered dedicated referral training for staff, ensuring they were confident and competent in making appropriate referrals. To further strengthen this area, the practice had created a detailed referrals resource pack, which included a directory of services available across the Dudley area. This resource supported staff, including locum clinicians, in identifying the most appropriate services for patients and facilitated timely and effective care coordination. The quality and innovation of this work had been recognised beyond the practice, with the resource pack shared with the Integrated Care Board (ICB) as an example of good practice to support wider adoption across the system.

Systems ensured that all patient information, including laboratory results and referrals, were reviewed and actioned promptly. Referrals to specialist and urgent services, including two-week wait (2WW) pathways, were managed through well-defined and consistently applied processes. The practice utilised clinical decision support tools, to aid the early identification and referral of patients with suspected cancer, supporting timely diagnosis and improved patient outcomes.

The practice demonstrated that effective processes were in place, which were consistently monitored and managed to maintain patient safety. For example, additional alerts were embedded within the clinical system to identify when patients had previously been under paediatric, Child and Adolescent Mental Health Services (CAMHS), or other specialist services. These prompts supported clinicians to proactively consider and discuss transitional care arrangements, ensuring continuity and appropriate planning as patients moved between services.

The practice operated a robust and responsive on call system, with a designated GP available on duty each day and based within the reception area to provide immediate clinical support and advice for queries. This enabled timely decision making, enhanced patient safety, and supported effective prioritisation of care. In addition, staff were supported by clear prompts and visual flashcards to ensure a consistent three-point patient identification check was carried out during all patient interactions, in line with information governance requirements.

The service demonstrated a strong, proactive safeguarding culture, working effectively with people and system partners to understand what safe care meant and how best to achieve it. There was a clear organisational focus on improving outcomes while protecting people from abuse, discrimination, avoidable harm and neglect. Concerns were identified early and consistently shared appropriately.

Robust safeguarding governance arrangements were in place. Policies were comprehensive, embedded in practice and well understood by staff, including supporting procedures such as did not attend, chaperone and mental capacity processes.

Safeguarding leadership and accountability were clearly defined. There was a named GP lead for safeguarding and appointed safeguarding leads within each department. All staff contributed to safeguarding oversight and safeguarding representatives attended monthly multidisciplinary meetings alongside the health visitor, social prescriber and school nurse. Following quality improvement initiatives, safeguarding meetings were strengthened. A live safeguarding log was made accessible to all staff on an ongoing basis, enabling them to report soft concerns, behavioural changes, or significant issues as they arose. This approach ensured that concerns were recorded contemporaneously rather than retrospectively, facilitating earlier discussion and intervention.

The process supported the identification of patterns of concern over time, resulting in measurable improvements in recognition, escalation, and coordinated response. For example, over a 16-month period, 687 patients were reviewed, with an average of over 40 cases discussed each month. Of these, 60–80% required active intervention, demonstrating effective risk identification and timely action. Evidence from 2 case studies further demonstrated that prompt multi-agency collaboration and engagement led to positive outcomes. Governance arrangements were also strengthened through clear documentation, systematic action tracking, and improved auditability.

The practice maintained a register of vulnerable patients and worked collaboratively with external agencies to manage safeguarding concerns. Where communication challenges were identified with the Dudley Safeguarding Team, these were appropriately escalated by leaders, resulting in improved communication and strengthened partnership working. Learning from this engagement at the time of our assessment was being shared and implemented across the wider locality to support more consistent safeguarding processes.

We found that systems supported consistent and timely safeguarding action. Embedded clinical prompts, clear referral pathways and quarterly audits ensured oversight and quality assurance. Patients approaching transition points, such as age 18, were appropriately flagged to prompt review and continuity planning within the clinical record.

All staff were up to date with safeguarding, Mental Capacity Act and Deprivation of Liberty Safeguards training. Staff undertaking chaperone duties had enhanced DBS checks.

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.

Staff demonstrated a strong understanding of emergency protocols and had received appropriate training in basic life support and sepsis.

Reception staff were knowledgeable about the actions required if they encountered a patient who was deteriorating or acutely unwell and had been provided with clear guidance to support the recognition of such presentations. To reinforce safe and effective decision making, practical tools had been developed for non-clinical staff. This included a noticeboard in reception including sepsis and patient prioritisation flowchart, enabling staff to assess urgency and ensure patients were managed and escalated appropriately.

In addition, a structured flowchart and guidance resource was in place to support staff when handling patient calls, helping them to identify the nature and severity of conditions and respond appropriately. This combination of training and accessible guidance supported timely intervention and promoted patient safety.

Patients were advised about risks related to their condition and the actions to take if their symptoms deteriorated. Staff were aware of the location of emergency medicines and equipment, which was appropriately maintained. The practice also held registers to support patients who were vulnerable or who had mobility or communication needs.

The service was fully aware of all potential risks in the care environment and controlled them well. They made sure equipment, facilities and technology supported the delivery of safe care.

The practice premises were owned by the GP partners. At the time of the assessment, there were plans in place to expand capacity through the addition of 2 further consulting rooms.

A health and safety noticeboard was accessible to staff within the office area, promoting awareness and a safe working environment. It displayed clear and up-to-date information, including guidance on posture and safe working practices, workplace risk assessments, manual handling, the health and safety law poster, and the personal protective equipment policy.

Robust systems were in place to monitor compliance with mandatory health and safety risk assessments, premises, security, fire safety and legionella testing. These systems were well embedded and consistently implemented to ensure the ongoing safety of patients and staff. Fire safety processes were particularly strong; weekly fire alarm tests were undertaken, and all staff were trained fire marshals. Staff had completed comprehensive fire safety training and participated in regular fire drills, which included full evacuation procedures.The practice told us that all administration staff members were appointed as fire marshals to ensure there is always a fire marshal on duty and staff are confident and capable of responding effectively in an emergency.

Policies and procedures were in place to support the effective management of health and safety. The practice carried out regular environmental audits, with any identified actions addressed promptly. Learning from these audits was shared through well-established internal systems, fostering a strong culture of continuous learning and improvement.

All electrical equipment had been appropriately calibrated, and safety tested in line with regulations. Safety alerts relating to equipment were effectively disseminated to relevant staff and acted upon in a timely manner, ensuring risks were minimised.

The practice demonstrated a proactive approach to managing risks associated with power outages. Following previous incidents, leaders had implemented effective mitigation measures, including the purchase of a backup generator to maintain the safe storage of medicines within fridges. They had also introduced digital monitoring systems, with mobile apps providing real time alerts to leadership staff if fridge temperatures fell outside safe limits, outside of normal operating hours.

The practice environment was clean, well maintained and accessible to all patients, including those with mobility needs, with sufficient space for wheelchairs and prams. Hallways and corridors were free from clutter and staff areas were secure, with restricted access maintaining both safety and confidentiality.

The practice had a designated confidential area to support patients’ privacy and dignity during confidential discussion and in an emergency situation. Additional measures, such as portable privacy screens, were available to ensure dignity could be maintained if care needed to be delivered in communal areas.

Arrangements for accessing emergency equipment were robust and well embedded. Effective systems were in place for the checking and monitoring of emergency equipment and medicines. The practice held all recommended items, including oxygen and an automated external defibrillator (AED). An exceptionally well organised emergency trolley was in place, featuring clear labelling, prominent signage and accessible written instructions, enabling staff to respond promptly and safely in high pressure situations.

Access to emergency equipment was carefully risk assessed. An additional emergency key was securely stored in a clearly identified “break glass in emergency” location, known to all staff. This ensured rapid access when required, while maintaining appropriate security controls. The practice maintained a business continuity plan that provided structured guidance in the event of significant service disruptions, including IT system failures.

Overall, the practice demonstrated an embedded and proactive safety culture, with highly effective systems that enabled risks to be consistently identified, managed and learned from. These arrangements ensured the environment, equipment and facilities were well organised to support the delivery of safe and high-quality care.

The service made sure there were always enough qualified, skilled and experienced staff, who received thorough support, supervision and strong development opportunities. They worked together well to provide safe care that met people’s individual needs.

An effective on call system was in place, with a designated GP available each day and based within reception. This enabled real time senior clinical oversight, including reviewing urgent requests, supporting care navigators, managing demand when same day capacity was exceeded, making decisions regarding home visits, and supervising trainees and non-medical clinicians. This approach strengthened risk management and supported timely, safe decision-making.

A role specific induction process was in place for all new staff, which was required to be completed within 4–6 weeks of employment. Leaders ensured staff competency following induction through structured assessment, including completion of a knowledge-based quiz, to confirm they were suitably prepared to carry out their roles safely and effectively. Staff described the induction process as comprehensive and supportive.

Staff training was comprehensive and up to date, with clear systems in place to identify and support learning and development needs. Staff consistently worked within their defined competencies and reported that both their professional development and wellbeing were prioritised by leadership. A structured programme of clinical supervision and regular audits was in place to provide oversight, support and assurance that staff were working within the agreed scope of their roles and maintaining high standards of practice.

There was a strong culture of progression, with staff supported to take on additional responsibilities, including lead roles. Opportunities for further training were actively encouraged and aligned to both individual aspirations and service requirements. Annual appraisals focused on performance, development and wellbeing, and were aligned with the organisation’s vision and values.

Safe recruitment practices were consistently followed, as confirmed by a review of personnel files. Records of staff immunisation status were maintained. All staff, both clinical and non-clinical, were appointed a supervisor. The practice also benefited from a multidisciplinary team through its Primary Care Network (PCN), including pharmacists, a social prescriber, physician associate, and first contact practitioners in mental health and musculoskeletal care. Systems were in place to ensure these staff were safely recruited, appropriately trained, and working within their scope of practice.

Staff were supported through protected learning time, with the practice regularly holding dedicated learning sessions to support development, shared learning and continuous improvement. These sessions facilitated team development, shared learning, governance discussions and reflection on significant events, quality and safety. Additional opportunities, including in-house training, conferences and external courses, were encouraged to further enhance staff knowledge and skills.

Staffing and workforce planning was proactive, and data driven, with regular reviews and quarterly analysis of patient list growth to ensure staffing levels remained appropriate and responsive to demand.

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 completed relevant training. An annual IPC audit was undertaken, and the most recent audit, in February 2026, showed the practice had achieved a compliance score of 95%, with identified actions all completed.

Systems were in place to assess, monitor and mitigate infection risks. Comprehensive policies included relevant partner contact details, and regular IPC audits and risk assessments. Action plans were developed and implemented promptly to address identified risks, ensuring continuous improvement.

The environment was visibly clean, well maintained and appropriately equipped to support safe care. Clinical rooms were suitably stocked with essential equipment, including personal protective equipment (PPE), pedal bins and hand hygiene facilities. Cleaning arrangements were effective, with contracted cleaning staff in place and cleaning schedules consistently followed. Cleaning areas were well organised, appropriately stocked, and utilised single use equipment to reduce cross contamination risks.

Innovative systems supported ongoing assurance of cleanliness and safety. For example, each clinical room displayed a QR code, which staff were required to scan daily to confirm the room had been checked, cleaned and appropriately stocked. This provided real time oversight and accountability.

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.

The practice was supported by clinical pharmacists from the local Primary Care Network (PCN) to monitor people and the prescribing of medicines. As part of our assessment, we carried out remote searches of clinical records to check how the practice monitored patients’ health in relation to the use of high-risk medicines.

Clinical searches identified that 1 of 37 patients prescribed methotrexate, an immunosuppressant, had overdue monitoring in the previous 6 months. On review, this patient had recently initiated treatment under secondary care. A further review of 3 records found that, although monitoring arrangements were in place, it was not always clearly visible whether a shared care agreement had been established. The practice advised that this information was documented within the clinical records but acknowledged that additional coding or alerts could enhance the visibility of accepted, declined, or pending shared care arrangements.

We also identified 33 patients prescribed angiotensin-converting enzyme (ACE) inhibitors, commonly used to manage hypertension and heart failure, who were overdue monitoring. A review of 5 records demonstrated that patients had been

recalled on multiple occasions, although some remained overdue for blood pressure checks. We discussed the processes in place for patients who fail to attend appointments despite receiving multiple recall notices. The practice explained that patient needs are individually assessed and regularly reviewed. Additionally, a new IT system for managing recalls was introduced in March 2026 to enhance oversight, improve efficiency, and strengthen risk management.

We identified 9 patients with asthma who had been prescribed a short-acting beta-agonist inhaler within the last 12 months. A review of 4 patient records highlighted opportunities to strengthen systems for managing patients requesting multiple inhalers. During the inspection, the practice implemented an additional alert within the clinical system to improve clinician visibility of recent exacerbation management to support proactive reviews, safer prescribing, and timely escalation where required.

The provider demonstrated systems to manage safety alerts issued by the Medicines and Healthcare products Regulatory Agency (MHRA). A clinical search identified 45 women of childbearing age prescribed teratogenic medicines, which carry risks during pregnancy. A review of one record found no documented pregnancy prevention plan. The practice advised that this had been requested from secondary care, and evidence was seen that information outlining key risks had been shared with the patient electronically.

Staff involved people in reviews of their medicines and 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.

The practice utilised Patient Group Directions (PGDs) to ensure the safe administration of immunisations and all documentation was properly authorised and signed. 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. The practice had policies in place to manage and minimise any risk of patient disengagement. For example, clinical disengagement policy.

Medicines including controlled drugs were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines, vaccines, and controlled drugs. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments.

There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.

Prescribing data reviewed as part of our assessment showed that the practice’s performance was in line with national averages for pregabalin and gabapentin, psychotropic, hypnotic and antibiotic medicines.