Wellington Road Surgery

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 clinical and nurse meetings held, the team discussed and learnt from clinical issues. Staff felt 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. Those sampled were managed effectively. The practice told us they would carry out 6 monthly analysis of events going forward to help identify trends and themes.

There was a system to record and investigate complaints. The practice had received 20 complaints in the previous 12 months mainly in relation to getting through to the practice by phone or about clinical missed diagnosis. When things went wrong, staff apologised and gave people support. Learning from incidents and complaints resulted in changes that improved care for others. Staff told us they would welcome more feedback on the outcome of complaints and any common trends and themes.

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 were managed in a timely way. At the time of our site visit the practice had a significant backlog in relation to coding and saving incoming correspondence into electronic patient records, such as test results, hospital reports, and administrative paperwork. An assessment to mitigate the risk had been carried out and all incoming correspondence was being reviewed and triaged by GPs. Work was also being outsourced to manage the backlog.

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 had a designated safeguarding lead, deputy and co-ordinator and staff were aware of these leads and how to report concerns. The service shared concerns quickly and appropriately.

Safeguarding policies were in place and known to staff. Most staff had received the appropriate level of training in safeguarding procedures. Reception staff had completed level 1 safeguarding training rather than Level 2. The practice told us they would ensure reception staff completed Level 2 safeguarding training as soon as possible. The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations.

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. 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 in the event of a medical emergency and had received training. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Contracts were in place to ensure the premises were maintained. Health and safety risk assessments and audits had been undertaken. Staff received training in safe working practices and told us they had no concerns about health and safety.

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. The practice worked together well to provide safe care that met people’s individual needs.

The practice directly employed 49 staff with a range of clinical and non-clinical roles supported by staff from the Primary Care Network (PCN). We found training was up to date, learning needs and development of staff was managed appropriately. Staff were encouraged to develop their skills and knowledge. A member of staff had been supported to train in phlebotomy, and another was booked to attend a British Sign Language course. Safe recruitment practices were followed. Some staff told us the team would benefit from additional reception staff and dispensing staff particularly to cover unplanned absences such as staff sickness. Leaders acknowledged that more resources were required across some teams.

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. Staff had access to a range of policies relating to infection control. An Infection prevention control (IPC) annual statement report was available on the provider website, which was reviewed annually.

The practice had a designated IPC lead and link nurse, and staff had had relevant training. Cleaning staff were directly employed by the practice and ensured cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks. The practice told us no complaints or significant events had been raised in relation to IPC. Areas of the practice we sampled during the site visit were clean and uncluttered.

Staff immunisations to potential health care acquired infections were not up to date and risk assessments had not been completed to mitigate potential risks. The provider was aware of this shortfall and had a plan in place to address this issue. This included the development of a new staff vaccination policy.

Medicines and medical gases at the practice were stored securely and at appropriate temperatures.

The practice managed prescription stationery securely, and in line with national NHS guidance. Paper prescriptions were tracked safely within the practice.

We inspected the dispensary and found that prescriptions were always signed by a prescriber on the day they were issued. Robust processes were observed in the dispensing of medicines with staff who were appropriately trained and knowledgeable. Expiry dates of medicines were checked, and the stock in the dispensary was in date. However, the provider’s policy was not followed to record short-dated stock. For dispensing errors, a near-miss book was available, and these were discussed in meetings with staff to share learning.

Controlled drugs (CDs), medicines requiring additional security measures due to the potential for misuse and diversion, were stored securely.CD balance checks were completed at regular intervals, and we found all stock levels to be accurate. We found that the CD registers were written under generic medicines and did not always include the brand names. This did not follow best practices for CD record-keeping.

Staff had the appropriate authorisations in place to administer medicines under Patient Group Directions (PGDs).

Emergency medicines were in place to manage patients presenting with emergencies, and they were checked regularly. However, we identified several issues relating to the organisation and clarity of emergency medicine arrangements. In the main treatment room, there was no list of emergency medicines stocked or where to find them in the practice. This meant staff did not have immediate access to clear guidance in an emergency. In addition, there was no clear guidance on the minimum quantities of emergency medicines to be kept on site. For an emergency medicine to be kept in case of sickness, a list of medicines was provided, and these were expected to be kept in the dispensary. However, we found this was not the case on the day of our site visit. These issues were raised with the provider and have been since addressed.

We carried out remote searches of clinical records as part of our assessment to review how the practice monitored patients’ health in relation to the use of medicines. The searches demonstrated that monitoring processes for high‑risk medicines were generally effective, and we saw evidence that MHRA alerts were reviewed and appropriately actioned. Searches relating to the management of long‑term conditions showed that patients with diabetes and chronic kidney disease were being followed up and monitored in line with recognised guidance.

However, when we reviewed a sample of medication reviews, we found these were not always completed to an adequate standard. We examined 5 records and noted that reviews lacked sufficient detail, with limited evidence of structured discussion or documented consideration of risks. For patients prescribed medicine for nerve pain (gabapentinoids), oversight was inconsistent. Of the 5 records reviewed, 2 patients had not received a meaningful review for several years, and there was no documentation to show that the risks associated with long‑term use had been discussed. This indicates that the practice’s approach to medication reviews was not always robust, with improvements required to ensure reviews were comprehensive, regular, and clearly documented in line with best practice. The practice advised that this work was ongoing, and these patients had since been reviewed.