Albion Health 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.

This key question has been rated Requires Improvement. There was a risk that patients were not protected from abuse and avoidable harm. This meant some aspects of the service were not always safe and there was limited assurance about safety.

The service was in breach of one legal regulation in relation to safe care and treatment, in particular, health and safety, infection prevention and control, medicines management and safe and effective staffing. The provider was keen to improve and was responsive to feedback when we raised concerns with them.

After the assessment, the provider informed us of immediate improvements they were making in response to our findings. We will review these at our next assessment.

This service scored 41 (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 did not always have a proactive and positive culture of safety based on openness and honesty. They did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice. We identified some risks that had been overlooked. The service had a significant event and complaints policy. There were processes for reporting, recording and acting on incidents and staff carried out significant event analysis (SEA). Staff told us they could raise concerns and report when things went wrong. Staff told us that incidents were discussed during team meetings, and the learning outcomes were shared with staff. However, from our review of meeting minutes, it did not appear that significant or clinical events or safeguarding was a standing agenda item for discussion. For example, minutes from a practice safeguarding meeting did not record the learning from a child safeguarding concern in April 2024 or record the changes that had been made as a result of identified learning. When we raised this with leaders, they told us that learning from incidents was logged on the SEA tracker. Leaders told us they had recently subscribed to a software programme to improve recording of incidents and also log SEAs as a learning event, which all staff would have access to.

There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. CQC received 2 complaints in the last 12 months from people who used the service. We received some negative feedback about people’s experience of the complaints process and how the practice had communicated information to people, about registering with the service.

The practice had received 18 written complaints in the 12 months leading up to the assessment. From information we reviewed, we saw that the service had contacted people who had complained to provide them with a response and that complaints and outcomes were discussed in monthly practice meetings. However, we identified that although the practice had sent acknowledgement letters for complaints, written responses had not always been sent in line with their internal protocol to ensure that even when complaints were resolved verbally, a written response would still be issued.

When negative comments were left through the Friends and Family or eConsult surveys, the practice discussed the comments and how to improve the service in practice meetings. Leaders had met to discuss the results of the 2024 National GP patient survey, and an action plan had been formed. The practice had not conducted their own patient survey. The practice had a duty of candour policy in place.Since our assessment, the provider had launched an in-house patient satisfaction survey in collaboration with the practice Patient Participation Group. Leaders told us survey findings would be used to improve service delivery.

We asked the provider to place a link on their website to the Give Feedback on Care process so we could hear of patients’ experiences of care. We received 22 pieces of feedback. Feedback we received from people was mostly positive with people feeling supported by helpful, caring staff and feeling staff treated them with kindness and understanding. We spoke with a member of the Patient Participation Group, and they raised no concerns relevant to this quality statement and reported the service always listened to their feedback.Leaders acknowledged the safety concerns we identified during the assessment and told us they took them very seriously. After the assessment, the provider informed us of actions they had taken to strengthen systems and processes. We will review these at our next assessment.

The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services. Our review of patients’ records and the clinical system indicated that letters, referrals and blood tests results were managed and responded to safely. The provider could mostly demonstrate that all communication was reviewed and acted on appropriately.

There was a system to ensure referrals to specialist services were documented and contained the required information. The practice had processes in place to monitor urgent (2 week wait) referrals that had been made. There were effective safety netting processes in place to ensure all patients were followed up.

During our inspection, staff were not able to show us an audit trail that showed a result was received back by the practice for every cervical smear sample taken. We saw that there was a safety netting process in place for auditing inadequate smear results received. Following our inspection, leaders told us they would use a safety netting audit template for monitoring the receipt of cervical smear test results and that the audit would be run on a regular basis.

There were systems in place for processing information relating to new patients. The service had a new patient registration policy. We found the practice had effective processes for registering new patients and summarising their records.

Since our assessment, the provider told us they have reviewed their processes for tracking cervical smear results and updated the new patient health questionnaire to promote equality and support people to access the service. Leaders told us the service is currently awaiting accreditation for the Pride in Practice programme.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. The service shared concerns quickly and appropriately. 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. However, some processes to make sure people were protected from abuse and neglect required improvement.The management team had safeguarding systems and processes in place, these were up to date and in line with local guidance. The practice had a lead for safeguarding adults and children. All staff we spoke with were aware of who the lead was and how to escalate any concerns they had.

Regular safeguarding multidisciplinary meetings were held to discuss safeguarding concerns. Safeguarding registers for both children and adults were maintained and there was evidence of reconciliation of the registers. Alerts were put on the records of patients identified as being at risk from abuse. This included children on the child protection register, children of concern and looked after children. Families of patients identified as at risk were linked and had alerts on their records.

Information on the local safeguarding processes and who to contact was available to staff should they have a concern. However, training records showed not all staff had received safeguarding training to the appropriate level. For example, our review of safeguarding training identified four reception staff who had not completed level 2 safeguarding children and one member of reception staff who had not completed level 2 safeguarding adults. This was not in line with intercollegiate guidance. All staff we spoke with said they were confident about raising any concerns and knew who to report any safeguarding concern to. Following our assessment, the provider sentus evidence confirming all staff had completed safeguarding training, relevant to their role.

We saw that Disclosure and Barring Service (DBS) checks were undertaken for all staff, in line with the practice policy. DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable. Chaperones we spoke with were aware of their roles and responsibilities.

The provider did not always work with people to understand and manage risks enabling them to make informed decisions. During this assessment, we found not all clinical staff understood the procedure for acting on safety alerts and the checks they should make to ensure action was taken. Patients were not always informed of any adverse effects of the medicine they were taking.

Emergency equipment was available and maintained. The practice was equipped to deal with medical emergencies (including suspected sepsis) and staff were suitably trained in emergency procedures. Staff could recognise a deteriorating patient and knew of action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

The service operated an online consultation service, where patients could contact the service using a digital platform or by phone. The service had a team of patient advisors who triaged and signposted all requests for support at the first point of contact. A duty doctor hub supported the patient advisor team who had access to a clinical and non-clinical triage flowchart. Reception staff had the support of a duty doctor to enable them to respond to patient needs. We did not receive direct feedback on patient involvement in managing their care and treatment.

The provider acknowledged the patient safety concerns we raised during the assessment and took them very seriously. Since our assessment.Since our assessment, leaders took prompt action to strengthen practice systems to ensure patients are appropriately reviewed and informed of any medication-related risks.We will review these changes at the next assessment to see if they are effective and have become embedded into practice.

At this assessment, we found the provider did not always detect and control potential risks in the care environment. The provider had not made sure equipment, facilities and technology supported the delivery of safe care. The practice was on the ground floor of an older listed building leased from a landlord. The floors above the practice had been converted into residential flats. The provider had responsibility for maintenance of the area occupied by the service.

The provider did not have effective arrangements to monitor the safety and upkeep of the premises. For example, we found the provider could not demonstrate effective systems to manage fire risk. Although, the practice manager had completed a fire risk assessment in November 2024, we were not assured that it was adequate, as we identified some fire safety hazards from a stack of leaflets stored inside a locked electrical cupboard in the reception area and fluorescent glass lighting tubes stored in the fire alarm board cupboard in the corridor. The door to the room where oxygen was stored was not labelled with a sign to warn people of a potentially hazardous area. Leaders appeared to be unaware of the fire risk.We asked managers to take immediate action and staff removed the stack of leaflets and safely disposed of the fluorescent glass lighting tubes and put a sign up to warn people of the potential hazard of stored oxygen.

We found the practice had not regularly reviewed fire safety procedures. For example, the practice had a fire safety policy, but there was no written procedure for evacuating the premises. There was no fire evacuation floor plan of the premises available, and no fire action plan displayed to ensure effective response to any fire emergency. There had been no regular fire door inspections and user checks to ensure fire doors could function properly in the event of a fire. We saw some doors wedged open with door wedges, one of which was a fire door.

The service had arranged for an engineer to carry out maintenance testing of the fire alarm and control panel in December 2024. However, the weekly fire alarm testing log showed a gap between November 2024 and February 2025 when no testing was recorded. Immediately following our on-site inspection, managers took action to review fire safety procedures and arranged for a fire risk specialist from an external fire assessment service, to carry out a full fire safety risk assessment on 21 March 2025. The practice manager had completed fire safety training and fire warden training.

Leaders acknowledged the fire safety concerns we identified during the assessment and took them very seriously. Since this assessment, the provider informed us weekly fire alarm testing is now conducted and logged, a fire evacuation drill has been carried out, fire exit signage and floor plans, along with a clear fire action plan are now displayed prominently throughout the premises. All fire door wedges we identified have been removed, and every door in the practice has been made compliant with fire safety standards. Leaders told us they maintain an up-to-date risk register to ensure all issues are logged and actioned. We will review these actions at our next assessment, to see if they are effective and have become embedded into practice.

The provider told us that equipment was maintained according to manufacturers’ instructions. The practice provided evidence of annual portable appliance testing, and calibration of equipment. All staff had completed their mandatory fire safety training. During the inspection we reviewed the practice risk register but found this was not routinely used to document risks relating to health and safety. The risk register did not include action plans for managing all identified risks. There was a business continuity plan in place which was monitored and reviewed.

Most staff training was up to date, and most staff were working within their agreed areas of competence. However, managers had not always ensured learning needs and development of staff was managed appropriately. Although the provider used computer software to track mandatory staff training, some non-clinical staff had not received level 2 training in the safeguarding of children and adults. This was recommended by the Royal College of Nursing’s (RCN) intercollegiate guidance for all staff who work in health care who have regular contact with patients. Following this assessment, the provider sent us updated information confirming all staff had completed safeguarding training relevant to their role.

Further assurance of role specific training was required from some of the non-clinical staff to ensure they were competent for their role. For example, the IPC lead had not undertaken additional IPC lead training. Two health care assistants had not completed training updates regarding phlebotomy since 2006 or 2012. Following our assessment, staff completed this training and leaders told us this would be recorded on the practice’s risk register to ensure regular review.

All staff were encouraged to attend training to support them in their roles. For example, non-clinical staff had completed training in care navigation, young people’s access to health, supporting digitally excluded patients, customer experience, and Pride in Practice.

Clinical staff and non-medical prescribers received support and supervision, but meetings and prescribing parameters were not routinely documented. Where clinical consultations had been discussed with a GP, this was recorded in the patient record. Since our assessment, the provider had strengthened their processes to ensure structured supervision meetings and consultation reviews are formally documented. Leaders had also introduced scheduled debrief slots for Advanced nurse practitioners and GPs within their clinics.

The practice submitted a recruitment policy last reviewed in March 2025, which included the required checks to ensure safe recruitment. Safe recruitment practices were followed.

The provider did not have an effective approach to assessing and managing the risk of infection, which was in line with current relevant national guidance. Roles and responsibilities around infection prevention and control (IPC) were not clearly identified. The service had an IPC policy, but staff had not always followed it.

A formal Infection prevention and control audit was carried out by NHSE England in May 2024. The practice scored 96.7% compliance with 5 recommended actions. Although the practice had taken some actions following the May 2024 IPC audit, we were not assured that staff had carried out IPC checks in between the yearly audit. For example, although there was a cleaning schedule, staff had no oversight or system of checking which cleaning tasks had been completed by the cleaning contractor and that they had been done at the recommended frequency.

We observed areas in the premises had not been cleaned effectively and were an infection control risk, in particular there were marks on the walls and the flooring in the consultation rooms and in the general areas. Processes to monitor that cleaning by the cleaning company met IPC standards were not effective. We observed that the flooring in treatment room 9 was stained and dirty. Room 9 was used to carry out minor surgery procedures. When we raised this with managers, they were not able to show us the deep clean protocol or whether it had been done at the recommended frequency.

There was no COSHH risk assessment available. Staff were not able to show us any data sheets for substances stored on the practice premises. Staff we spoke with were not aware they had to have a COSHH risk assessment.

The infection prevention and control lead for the practice had not had additional IPC training for their role. We saw that IPC induction was included in the practice induction checklist, but staff told us there was no formal staff IPC induction carried out and no annual hand washing audit completed. We observed that the practice had fabric curtains in most of the consultation rooms. We saw a written schedule for recording when the cleaning contractor took down the curtains to be cleaned which was six monthly, or before if the curtains were dirty. However, the service did not have a policy to record clearly when the fabric curtains were last cleaned and we could not find any indication on the curtains in the clinical rooms.

Staff told us they were responsible for wiping down surfaces and equipment in the consultation rooms in between patients and/or at the end of the day. The clinical rooms had the necessary equipment for patient examination and PPE was readily available. Staff told us they had a good relationship with the cleaning staff, and they were able to raise concerns with them about the quality of cleaning. A legionella risk assessment was carried out in November 2024; however, we found there was no written scheme of control and no responsible person. Most staff had completed infection prevention and control training.

We asked the provider to take action to improve infection prevention and control. Following our inspection the provider told us they had completed a handwashing audit and implemented a monitoring process to check cleaning compliance. Leaders sent us evidence of completed additional IPC NHSE training and that deep cleans would be recorded, checked and signed off by the IPC lead.Since our assessment, the provider told us they have taken action to strengthen practice systems in order to maintain a clean, safe, and well-managed environment for both patients and staff. We will review these changes at the next assessment to see if they are effective and have become embedded into practice.

The service did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. The provider did not have effective systems to manage and respond to safety alerts and medicine recalls. Leaders had not established processes to ensure people prescribed medicines with specific risks received recommended monitoring.

Staff had not always involved people in reviews of their medicines and helped them understand how to manage their medicines safely. The practice had not always responded appropriately to drug safety alerts. The practice policy did not detail when and how often searches should be run for previous and historical patient safety alerts. The service did not submit evidence of historical patient safety alerts that remained clinically relevant. Following our assessment, leaders told us they had updated the safety alert policy to include regular searches for previous and historical patient safety alerts. Leaders told us they had created designated clinical leads to improve management of safety alerts.

People’s medicines were not always appropriately prescribed, supplied and administered in line with the relevant legislation or current national guidance. We found some staff had not always followed the prescribing policy to ensure they prescribed all medicines safely.

As part of our assessment a number of set clinical record searches were undertaken by a CQC GP specialist advisor. These searches were visible to the practice.

We looked at a sample of patients on high-risk medicines and found practice clinicians had not always checked the patient had the required monitoring tests and recorded the results into the patient record system. We found patients who were prescribed specific categories of medicines had not received appropriate monitoring. For example,

• patients prescribed a disease-modifying antirheumatic drug (DMARDS) had not received appropriate monitoring. We reviewed five patients prescribed high-risk medicines and found two patients who did not have up to date blood tests in their record. Some reminders for tests were sent to these two patients, but there was no evidence they had occurred.

• Patients prescribed ACE inhibitors or Angiotensin II receptor blockers (ACEI and ARB) had not received the required monitoring and there was no effective process of managing patients with raised blood pressure. We reviewed five patients and found that for all of these patients, there was no evidence that the prescriber checked that monitoring was up to date prior to issuing the prescription.

Patients prescribed oral anticoagulants had not received appropriate monitoring. This meant patients were at risk of not being recalled, followed up and reviewed which could result in serious risk to their health and wellbeing. For example,

• patients prescribed non-steroidal anti-inflammatory drugs (NSAIDs) had not received appropriate monitoring. NSAIDsre medicines that are widely used to relievepain, reduce inflammation, anticoagulant or antiplatelet medicine. We reviewed five patients over the age of 75 prescribed aspirin and found four patients who were low risk but there was no action documented to ensure their medication had been reviewed and medicines initiated to protect the stomach, where appropriate.

In line with NICE guidance our search identified patients who had two or more HbA1c readings in a range that would indicate diabetes (HbA1c > 48) without diabetes being coded in their records. The service could not demonstrate that prediabetic patients received appropriate follow-up and support. For example,

• We found not all prediabetic patients received appropriate follow-up and support. We reviewed five patients as having a potential missed diagnosis of diabetes and found three patients who should be on the diabetes register and no action had been taken to follow up and inform the patients of their diagnosis.

Patients were being sent text reminders to ask them to come in for monitoring, but staff didn’t act when patients didn’t respond. It was unclear as to whether alternative methods of communication were tried, and medication quantities adjusted to prevent potential harm. We raised these concerns with leaders. The senior GP partner agreed that not all staff were properly checking that monitoring was up to date and that it was safe to issue a prescription. The practice had completed 483 medicines reviews in the last three months; we reviewed five and found all had been completed satisfactorily.

The prescribing framework in place to administer vaccines was not always safe. In particular, our review of the Patient Group Directions (PGD) used by registered staff to administer medicines found that they were not all signed and up to date. These are legal documents under which qualified nurses and Healthcare Assistants can administer medicines and vaccinations. We found 6 PGDs which had been authorised for a member of registered staff, but they had not signed the PGDs. This meant that the member of staff was giving vaccinations without having signed the agreement to follow the PGD.

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. For example, the NHS Business Services Authority medicines data for the period 1 January to 31 December 2024 showed hypnotic, multiple psychotropics and antibacterial prescribing results were either in line or better than the national average.

Emergency medicines we checked were in date and stored appropriately, with access given to appropriate staff. Emergency medicines were accessible to staff in the event of an emergency. Staff managed prescription stationery appropriately and securely.

Since the assessment, the provider has shown a willingness to improve. For example, following our assessment, leaders submitted a structured quality improvement plan to address the medicines monitoring backlog and enhance monitoring processes. Weekly failsafe searches were introduced to reduce missed tests, and patient-focused messages were developed to encourage attendance at monitoring appointments. The service had subscribed to the Primary IT Toolkit software programme, which supports weekly clinical searches to optimise patient care. A designated team reviewed the data to ensure appropriate patient recall and management. The provider also collaborated with the Medicines Optimisation Team at the ICB to update the prescribing policy, focusing on high-risk medications. These changes will be reviewed at the next assessment.