Fordbridge 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 patients 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 requires improvement.

The practice was in breach of legal regulation in relation to safe care and treatment.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice encouraged a proactive and positive culture of safety, based on openness and honesty. Managers encouraged staff to raise concerns when things went wrong. The provider had processes for staff to report incidents, near misses and safety events.

We reviewed the significant events, complaints and other learning opportunities that had been recorded in the last 12 months. We found that during that period 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 noted there had been improvements in the last 6 months, including improvements to the recording and sharing of learning. However, there were still gaps in recording and identification of learning outcomes. We also found that not all complaints described during our assessment had been recorded.

Staff told us they believed that the culture was changing for the better and they would be listened to if they raised concerns. However, some staff told us they felt it was too early to tell whether the improvements would be sustained.

The practice worked with patients 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 patients moved between different services.

There were systems in place for processing information relating to new patients. The practice worked with other providers to deliver shared care and when patients moved between services. However, we saw examples where information received from other services had not been acted upon in a timely manner. Referrals and test results were managed in a timely way, although we found that test results could be managed in a way that would make it clearer for clinical staff.

The practice worked with patients and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving patient’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The practice 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 patients and acted on concerns working in partnership with other organisations.

The practice worked with patients to understand and manage risks by thinking holistically. They provided care to meet patient’s needs that was safe, supportive and enabled patients to do the things that mattered to them.

Triage was undertaken by doctors in the practice. Leaders in the practice told us they planned to develop a written protocol for triage, but this was not yet in place.

Emergency equipment was available and maintained. However, we found that some of the emergency equipment was past its expiry date. We found that some staff were not aware of signs and symptoms which could indicate a deteriorating patient. However, if they did recognise a deteriorating patient they knew of action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

The practice 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. Systems and processes for stock checking were not established to ensure that consumables were removed when they passed their expiry dates.

Health and safety risk assessments and audits had been undertaken. However, not all risks identified had been addressed. We also found that when the practice made changes, risk assessments were not always updated accordingly. For example, after relocating the oxygen storage from one room to another, the hazard signage was not updated to reflect the new location.

The practice 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 patient’s individual needs.

The practice employed a range of clinical and non-clinical staff. However, we identified significant gaps in training compliance and record-keeping. Evidence of role specific training was not always recorded by the practice. Not all patient-facing staff, including some clinicians, had completed mandatory training on learning disability and autism, which is essential for ensuring safe, inclusive care and meeting regulatory requirements. This lack of training increases the risk of inappropriate interactions and potential harm to vulnerable patients. In addition, staff undertaking lead roles were not consistently provided with sufficient training or supervision to perform their responsibilities effectively. While induction plans were in place for new staff, training was not always prioritised in a sequence that kept patients safe.

Records we reviewed did not demonstrate that safe recruitment practices in line with legislation were always followed. DBS (Disclosure and Barring Service) checks were not always carried out in line with the practice policy and where DBS checks had not been completed there were not documented risk assessments. There was a lack of processes in place to seek assurances or to confirm whether appropriate recruitment checks, or training had been undertaken by clinical staff employed by the Primary Care Network (PCN) but who were working under the direction of the practice.

The practice had a designated infection, prevention and control (IPC) lead. However, not all staff had completed relevant training. Cleaning schedules for clinical staff were in place and followed. However, we found that the general cleaning of the premises, including clinical rooms and patient toilets were not sufficient. For example, the flooring in the consulting rooms and the baby changing station were inadequately cleaned.Processes to monitor that cleaning by the cleaning company met IPC standards were not effective. These failings in the cleaning of the premises had not been acted upon, despite staff telling us they had raised concerns with leaders in the practice multiple times. We found that not all appropriate equipment was provided to clean up spills of bodily fluids.

The practice had a staff immunisation policy. However, we found that this was not always being followed, and the practice had not evidenced staff immunisations in line with UK Health Security Agency Guidance.

The most recent infection prevention and control audit had not been completed fully or accurately and had failed to identify all risks. The provider has told us that they had planned changes in the management of infection prevention and control, but these were not in place at the time of our assessment.

The practice made sure that medicines and treatments were safe and met patient’s needs, capacities and preferences. They involved patients in planning, including when changes happened.

Staff involved patients in reviews of their medicines and helped them understand how to manage their medicines safely. Patients 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 patients received all recommended medicines reviews and monitoring. Medicines were stored securely and at appropriate temperatures. However, we found that medicines fridges were overstocked which did not allow for sufficient air circulation to ensure an appropriate temperature was maintained throughout. Staff told us this was due to a lack of refrigerator space for seasonal flu vaccines.

Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines drugs. The provider had effective systems to manage and respond to safety alerts and medicine recalls. Staff followed established processes to ensure patients 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. For example, the number of antimicrobials issued by the provider was similar to local and national averages.