Ilkley and Wharfedale 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 people were protected from abuse and avoidable harm. At our last assessment, we rated this key question as good. At this assessment, the rating remains the same.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

There were some processes in place for premises maintenance and for health and safety risk management, including electrical maintenance, equipment calibration, and gas safety checks. However, remedial actions arising from risk assessments were not always actioned in a timely manner. For example, a Legionella risk assessment was undertaken in September 2023, however during our assessment we found that required high risk actions had not been completed. There were also no appropriate risk assessments for the control of substances hazardous to health. Although task-based risk assessments and safety data sheets were in place, these did not constitute a service-specific assessment of risks and control measures associated with each substance in use. In addition, there was only 1 record of a fire alarm evacuation drill, and no evidence of up-to-date fire warden training for any staff. In mitigation of this we saw that there were actions in place to control risks associated with fire and water safety which included the servicing of fire extinguishers, the testing and maintenance of fire alarms, and the regular checking of water temperatures. After our visit we saw that the service had arranged for necessary works and risk assessments to be completed and had arranged a face-to-face fire warden training session for relevant staff.

The service had a business continuity plan which outlined how the service should continue to operate in the event of a disruption.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support and development. They worked together well to provide safe care that met people’s individual needs. However, systems to monitor and maintain oversight of staff training were not robust. Processes relied on staff self-reporting completion, and periodic checks during appraisals for clinical staff, rather than a system of regular monitoring. As a result, the provider was unable to readily confirm the training status of all staff during our visit and had identified gaps in some training records following the assessment. Similarly, the system for staff immunisation oversight was not robust, resulting in the service realising during the assessment that some staff may not have received the required vaccinations. They told us this was due to a change in process which their external occupational health provider had not communicated to them. The service had since taken steps to strengthen oversight of mandatory training and staff immunisation through enhanced administrative access to its training and immunisation platforms.

The service included a range of clinical and non-clinical roles, which included GPs, nurses, and a pharmacist.

There were no formal, documented one-to-one clinical supervision sessions in place for all clinical staff. Staff told us that support was readily available as needed, and that regular clinical huddles provided opportunities to discuss cases and seek advice. Following the assessment the service implemented a system to provide regular, documented clinical supervision sessions for all clinical staff.

The service followed safe recruitment procedures when employing staff, which was in line with national legislation. This included identity checks, review of qualifications, obtaining professional references and a criminal records check.

The service assessed and managed the risk of infection and shared concerns with appropriate agencies where required.

The service had appropriate arrangements in place to ensure the premises and equipment were clean and tidy. Systems were in place to provide oversight of cleaning arrangements and support their effectiveness. During our onsite visit, the service's premises and a sample of equipment reviewed was noted to be visibly clean. The service’s infection prevention and control lead conducted regular risk assessments and audits to ensure compliance and took action to mitigate identified risks. It was however noted that several identified actions were reliant on planned building refurbishments.

Our review of a sample of staff training records showed that training in infection prevention and control had been completed.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.