Whitley Road Medical Centre

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 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 honesty. They actively listened to concerns about safety and thoroughly investigated and reported safety events. Lessons were always learnt to continually identify and embed good practice. Learning outcomes were shared with the Primary Care Network (PCN) ensuring anonymity of individual people.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. Representatives from the Patient Participation Group (PPG) told us that the provider took concerns seriously and proactively made improvements to the service. Regular meetings were held with the PPG to help keep members engaged and ensure that improvements could be made.

Managers encouraged staff to raise concerns when things went wrong. During staff meetings, the whole team discussed and learnt from clinical and non-clinical issues. Learning outcomes were shared with all staff following discussion to ensure those that could not attend due to other commitments did not miss out on important learning. Staff told us 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. Learning from incidents and complaints resulted in changes that improved care for others.

The service always worked with people and healthcare partners to design, establish and maintain safe systems of care, in which safety was always well managed and monitored. They made sure there was always continuity of care, including when people moved between different services. The practice supported people that had multiple long-term conditions.

The service had systems 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.

Patients with multiple health needs, including diabetes and Mental Health are seen jointly in the surgery to prevent secondary care referrals, improving outcomes for the patients and reducing the impact on local NHS trusts

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.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. The practice maintained a list of vulnerable people and acted on concerns, working in partnership with other organisations.

The service always worked well with people to fully understand and manage risks by thinking holistically. They provided care that fully met people’s needs and was safe, supportive and enabled people to do the things that mattered to them.

Emergency equipment was available and maintained. Staff could recognise a deteriorating patient and knew of action to take. All staff had been trained in emergency first aid appropriate to their role.

Following a medical emergency in the waiting area, staff responded, taking care to maintain the dignity of the patient. The practice recognised that staff on duty did not have clearly defined roles. Team met and discussed how they could improve the way they worked and a new system was put in place, where the lead clinician assigned individual roles and responsibilities to staff at the start of each day. This was shared verbally with staff already present and via internal communications to all staff.

Patients were advised on risks related to their condition and actions to take if their condition deteriorated or did not improve.

The service detected and controlled potential risks in the care environment. The service was in a managed building and it made sure equipment, facilities and technology under its control supported the delivery of safe care.

Where needed, contracts were in place and were reviewed regularly to make sure they continued to meet the needs of the service. Fire and health and safety risk assessments and audits had been undertaken and any risks identified had been addressed.

There was a business continuity plan in place which was monitored and reviewed.

Equipment checks and calibrations had been completed and there were records to show that these had been carried out periodically.

All non-clinical areas were clean, tidy and free from clutter. The waiting room was appropriately furnished and seating was in good repair with wipeable surfaces.

The clinical rooms were of a good clean standard. Handwashing facilities were appropriate with good levels of Personal Protective Equipment (PPE), hand towels and liquid soaps available for use. The privacy curtains were all in good repair and had been changed regularly.

Fire extinguishers were available and had undergone sufficient checks. There was good signage around the building telling people where to go and what to do in the event of a fire. There were fire doors in the building which had the correct signage on.

The service made sure there were always enough qualified, skilled and experienced staff on duty and employed by the practice. There were good contingencies in place to support short notice leave and sickness. Staff received support, supervision and development opportunities. They worked together well to provide safe care that met people’s individual needs. There were regular documented minutes of meetings and there was a clear visible working relationship between different grades of clinicians.

The practice had a range of clinical and non-clinical roles. Training was up to date, learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence. Safe recruitment practices were followed. Staff were up to date with vaccinations and risks assessments had been completed as per UK Health Security Agency (UKHSA) guidelines.

Feedback from staff told us that they felt completely supported within the workplace and that opportunities for learning were available to them to ensure they worked in the best interests of all service users.

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 lead and all staff had had relevant training. Cleaning schedules were in place and followed. Risk assessments and audits, including handwashing audits were completed, and actions were taken to mitigate risks.

We witnessed clinical staff were bare below the elbow whilst on duty which promoted effective hand hygiene.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They always 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 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 medicine and vaccines. Waste medicines were recorded and disposed of appropriately. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments.

The clinical system showed us that patients prescribed anti-coagulant medicines did not always have the correct checks in place to ensure safe prescribing. The provider took immediate steps to ensure that all patients on anti-coagulant medications were called in for follow up checks.

There was a smaller concern raised which highlighted that Medicines Health Regulatory Authority (MHRA) alerts were not always being followed, such as for the prescribing of Methotrexate (a medicine used to treat autoimmune conditions). The GP Specialist Advisor (GP SpA) conducting clinical searches saw only low numbers and the practice followed these patients up immediately following the inspection.

Overall theprovider 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. Patient Group Directions (PGD’s) and Patient Specific Directions (PSD’s) were in place and signed off and being followed correctly.