Ellergreen 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 remains the same.

This service scored 66 (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.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. Managers encouraged staff to raise concerns when things went wrong. During staff meetings, the whole team discussed and learnt from clinical issues. Staff felt there was an open culture, and that safety was a 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 led to improvements in care. For example, following an incorrectly recorded diagnosis during a new patient registration, the practice strengthened checks to ensure significant diagnoses were coded correctly, and discrepancies were escalated to a clinician.

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. 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.

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 practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations. However, they did not always share concerns quickly with all appropriate organisations. Safeguarding policies were in place and known to staff, however not all staff had undertaken training at an appropriate level. We discussed these observations during our assessment. The provider was receptive to our feedback and during our assessment we received assurance that action had been taken to mitigate any risk.

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.

Emergency equipment was available and maintained. 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.

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. However, 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. For example, a ceiling light in the cleaning cupboard had become detached from its mounting, exposing wires in the ceiling, a length of wiring originating from the roof had not been fixed to the wall or removed, and there was a loose handle on an emergency exit door. These observations were discussed during our assessment. The provider was receptive to our feedback. We received assurance during the assessment that action had been taken to mitigate risk including arranging an electrician to secure the ceiling light, make safe the exposed wiring to the exterior of the building and secure the loose door handle.

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

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

There were a range of clinical and non-clinical roles within the practice. Learning needs and development of staff were managed appropriately, and staff worked within their agreed areas of competence.

Most staff were longstanding. All staff were required to undertake mandatory training, including specific training to support autistic people and people with a learning disability. New staff received an induction programme. There were arrangements in place for covering staff sickness, absence and vacancies and the use of temporary staff was minimal. Staff told us they had protected learning time for them to undertake training, learning and professional development.

We looked at recruitment records for a sample of staff. These showed recruitment practices were not always conducted in line with legal requirements. For example, 2 recruitment files did not contain the required number of references and did not contain a record of immunisations. A third file did not contain evidence of professional registration or qualification checks. These observations were discussed during our assessment. The provider was receptive to our feedback. We received assurance during the assessment that action had been taken to mitigate risk.

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. Personal protective equipment was in good supply and located appropriately around the premises. The practice had a designated infection, prevention and control lead and all staff had received relevant training. Cleaning schedules were in place. Risk assessments and audits were completed, and actions taken to mitigate risks.

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.

We carried out a random selection of clinical searches to review how patients’ medicines were monitored and if the appropriate care and treatment was being received. These included a review of patients prescribed methotrexate, an immune suppressant medicine and checks to ensure patients with potential missed diagnosis of diabetes, were being reviewed appropriately. The review of a sample of patients’ records showed appropriate monitoring and reviews were being carried out in line with clinical guidance.

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. There was a process for recording and monitoring prescription stationery. However, this was not fully embedded throughout the practice or clearly documented. These observations were discussed during our assessment. The provider was receptive to our feedback. We received assurance during the assessment that action had been taken to mitigate risk.

Staff followed protocols to ensure they prescribed all medicines safely, and ensured people received all 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 medicines, vaccines, and controlled drugs. Waste medicines were recorded and disposed of appropriately including medicines returned by patients. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments. The provider 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. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.