Dr JI Solomon's 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 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 has changed to requires improvement because we found issues relating to medicines optimisation and infection prevention and control.

This service scored 62 (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. They felt the provider took concerns seriously and proactively made improvements to the service. 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 top 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 resulted in changes that 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 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 service 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 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.

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.

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 and risks identified had been addressed. 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. We found training was up to date, learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence. Safe recruitment practices were followed.

The service assessed and managed the risk of infection. The service detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. The practice had a designated infection prevention and control (IPC) lead and all staff had received relevant training. Cleaning schedules were in place and followed. There were safe and effective processes in place to safely receive biological specimens and dispose of clinical waste.

Risk assessments and audits were completed and the provider was acting on issues identified in the most recent audit from April 2025. The audit had not identified that hand wash basins within clinical rooms were non-compliant with IPC guidelines as they contained overflows and plugs, however the provider had recognised this issue and included it as an additional improvement within their action plan. The provider was working on addressing the following outstanding actions: replacing carpets in 2 consulting rooms (1 of which we were informed was not in clinical use);replacing fabric chairs in the waiting area; repairing cracks in the walls of non-clinical areas;and replacing hand wash basins in the clinical rooms. The provider informed us they would be applying for an improvement grant to assist with addressing the outstanding actions. They also planned to have an IPC audit undertaken by external IPC leads in the locality.

We noted that the premises were clean and patients did not report any concerns about infection prevention and control.

Medicines were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines. 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.

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 and felt confident managing the storage, administration and recording of medicines. Staff managed prescription stationery appropriately and securely.

Data reviewed as part of our assessment showed that the service was performing better than or in line with national averages for all prescribing indicators we reviewed. These prescribing indicators related specifically to medicines often used for nerve pain, mood or mental health, insomnia and bacterial infections. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.

However, our clinical searches identified improvements were required to ensure clinicians were prescribing safely:

• Patients prescribed methotrexate, a Disease Modifying Antirheumatic Drug (DMARD) which is commonly used to treat autoimmune conditions, had the appropriate blood monitoring in place prior to a prescription being issued.
• The searches identified some patients prescribed bisphosphonates (which are used to treat and prevent bone-related conditions such as osteoporosis) for over 5 years had potentially not received a bone density scan within the recommended period. We reviewed 5 of these patients and found 2 had up to date scans, 1 was no longer prescribed the medicine, 1 had a referral for a scan, and 1 was overdue a DEXA scan. The practice subsequently spoke to the patient who was overdue a scan and stopped prescribing the medicine. The practice also reviewed the remaining 4 patients identified on the searches and provided evidence from hospital correspondence that these patients had received a scan.
• The searches identified some patients prescribed warfarin (an anticoagulant which is prescribed to help prevent blood clots) had potentially not received blood test monitoring in the last 56 days prior to the prescription being issued. We reviewed 5 of these patients and found 4 patients did not have their most recent blood test result documented. During our inspection, the provider obtained the blood test results for 2 patients (results were in range) and 2 patients were asked to attend for blood test monitoring.
• The provider had systems to manage and respond to safety alerts and medicine recalls. However, the clinical searches identified 3 people prescribed a combination of medicines were overdue blood test monitoring. During our inspection, the provider located the results for 1 patient and contacted the remaining 2 patients to request they have repeat monitoring.
• The searches identified some patients with hypothyroidism who had potentially not received blood test monitoring in the last 18 months prior to a prescription being issued. We reviewed 5 of these patients and found 4 patients were overdue monitoring. We noted the practice did not have an effective process to follow-up when patients did not attend for monitoring.

The service was responsive to mitigate risks we had identified. They recognised improvements were needed to their internal policies and procedures to ensure that people prescribed medicines with specific risks received the recommended monitoring. They took immediate action by updating their prescribing policy, reviewing identified patients, documenting invitations and clinical decisions, reducing medicine quantities on repeat prescriptions where appropriate and until the required monitoring had been completed, and moving to paper-based requests (rather than the electronic prescription service) to prompt clinical contact. This approach to patient recall, safety netting and administrative oversight had been shared with all staff to ensure compliance with monitoring requirements.