Ombersley 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 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 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Leaders had a strong proactive and positive culture of safety, based on openness and complete honesty. They actively listened to concerns about safety and thoroughly investigated and reported safety events. Lessons were always learnt to continually identify and embed good practice. Staff felt supported to raise concerns and knew action would be taken and support provided if needed. Representatives from the Patient Participation Group (PPG) felt the provider took concerns seriously and proactively made improvements to the service based on the feedback they gave. 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 resulted in changes which improved care for others.

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 when patients moved between services. Referrals and test results were managed in a timely way. A duty GP reviewed all test results regularly during the day so these could be managed appropriately. For example, if someone needed to be seen in person they could be offered a same day appointment.

Safeguarding leads worked well with people and healthcare partners to fully understand what being safe meant to them and the best way to achieve that. They had a clear focus on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They always shared concerns quickly and appropriately. When required, the safeguarding leads attended multi-disciplinary meetings with other organisations.

Staff worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs which was safe, supportive and enabled people to do the things which 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.

Leaders detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Leaders ensured contracts were in place for the maintenance of the premises. Health and safety risk assessments and audits had been undertaken and risks identified had been addressed. For example, following a recent fire safety check actions were identified. Leaders took immediate action to ensure these were rectified and any risk to people was mitigated. There was a business continuity plan in place which was monitored and reviewed.

Leaders made sure there were enough qualified, skilled and experienced staff, who received effective support, regular supervision and development. They worked well together to provide safe care which met people’s individual needs. There were a range of clinical and non-clinical roles within the practice. We found training was up to date. Staff were encouraged to identify learning needs and development which leaders supported as they wanted staff to feel fulfilled in their roles. Leaders followed safe recruitment practices.

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. The practice had a designated infection, prevention and control lead and all staff had had relevant training. Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks.

Leaders and staff made sure medicines and treatments were safe and met people’s needs, capacities and preferences. 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. Staff managed prescription stationery appropriately and securely. Medicines including controlled drugs were stored securely and at appropriate temperatures in the dispensary. However, there were gaps in the fridge temperature monitoring in clinic rooms. This meant staff could not be sure medicines in the fridge had been stored at the correct temperature. Leaders took immediate action to resolve this by putting in easier to use monitoring forms and electronic devices which automatically recorded fridge temperatures.

Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines, vaccines, and controlled drugs. Leaders 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. However, there were no Patient Specific Directions in place. These forms were used when a medicine or vaccine was prescribed for an individual patient. They need to be signed by the prescriber so they can be administered by non-prescribing health care professionals. Leaders took immediate action to ensure these were in place and attached to each patient’s records. Leaders ensured there were suitable processes in the dispensary for staff to follow when dispensing medicines.