Hull Family 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 remains the same.

The service was in breach of legal regulation in relation to safe care and treatment and fit and proper persons employed.

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. However, not all safety incidents had been reported, recorded or investigated and staff had not always had feedback about reported incidents.

Managers encouraged staff to raise concerns when things went wrong. The provider had processes for staff to report incidents, near misses and safety events. Incidents were discussed and staff learnt from clinical issues during monthly staff meetings and protected time learning events. However, some staff told us they had not had feedback about safety events and did not attend meetings where these were discussed. A safety event relating to a stock check discrepancy had not been recorded and investigated. After the assessment the provider submitted evidence to show this had now been recorded and investigated, and learning was to be shared in a learning event.

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. One complaint relating to a misdiagnosis had not also been recorded as a safety event which may limit opportunities for learning. However, the lead GP told us this had been discussed as a safety event and learning had been shared with clinical staff.

There was a system in place for learning and sharing information about safety alerts. The pharmacists had created a log of patients to evidence where alert information had been acted upon. For example, where patients were prescribed a medicine which may be a risk in pregnancy, they were able to evidence where patients had been contacted. However, there was no system to regularly revisit historicalmedicine alerts, particularly when the provider had taken over another practice patient list, to ensure the guidance on the alert had been implemented appropriately. The pharmacists told us they would implement this.

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. Staff were knowledgeable about their roles and the systems in place to manage tasks relating to patient care. There were systems to prioritise their work and manage tasks in a timely manner. Systems were in place to monitor task lists and to manage and redistribute tasks in the case of staff absence.

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, these did not include the relevant agency contact details, but these were immediately updated, and a revised version was submitted after the assessment.

Staff were appropriately trained in safeguarding procedures.

The practice had lead clinicians in safeguarding for adults and children which were known to staff.

The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations.

Chaperones were available and clinical and non-clinical staff had received training in this area. The chaperone policy did not reflect that only clinical staff undertook chaperone duties.

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 the action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated. Following an event requiring emergency action by staff, all the systems were reviewed as a learning event and staff were supported.

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 and equipment were maintained. Evidence was provided for work completed where risks had been identified and for regular maintenance. For example, evidence of completion of work to repair electrical systems and clinical equipment maintenance records.

Health and safety risk assessments and audits had been undertaken and risks identified had been mostly addressed. Warning notices where oxygen cylinders were stored were not provided for all storage areas for example, at Park Health Centre although the need for this had been identified in the fire risk assessment.

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

Staff had received relevant health and safety training although some staff said they had not been part of a fire drill.

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. However, some processes such as clinical supervision and annual appraisals needed to be embedded into practice and recruitment policies and procedures had not always been followed.

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.

Some processes such as formal clinical supervision, assessment of clinical competence and annual appraisals had recently been developed and were in the process of implementation. There was a new system for annual appraisals which had been implemented in June 2024 and although some staff were yet to receive their annual appraisal, a plan was in place for these to be completed by the end of June 2025.

Required recruitment checks had not always been completed prior to staff commencing work. For example, in 2 of the 5 files checked 2 staff had no photo identification and 1 had no other form of identification on file. 1 had no disclosure and barring service (DBS) check and 1 member of clinical staff had a DBS check received after they had commenced work, risk assessments had not been completed to support the decisions relating to DBS checks. There was no evidence of qualifications for 2 nurses and 1 GP although relevant professional registrations were current. There was no health information including vaccination and immunisation status for 3 members of staff and no information for hepatitis B status for 2 clinical staff. A check list was to be implemented to assist the recruitment process.

The practice was a training practice and provided doctor and GP training for students at Hull and York Medical School and Kings College London, GP registrar training and foundation year 2 doctors placements. Staff told us they felt well supported and had received training for their role. They said they had been supported to develop and gain qualifications to progress their career. There were several staff who had been supported to develop and progress through the organisation and staff were extremely positive and passionate about their roles.

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 staff had had relevant training. Staff had dedicated time for cleaning tasks and cleaning schedules were in place and followed.

Risk assessments and audits were completed, and actions taken to mitigate risks.

We found some sharps bins had not been correctly labelled. Immediately following the assessment, the provider submitted evidence this had been addressed and a reminder sent to staff responsible. The reception screen at Park Health Centre site was not clean due to remnants of sticky tape left on the glass.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. The service did not always ensure medicines were safely and securely stored.

Staff involved people in reviews of their medicines although not all records of medicines reviews were adequately detailed.

Prescription stationery was not managed appropriately and securely. After the assessment the provider submitted evidence of an updated policy and procedure and new recording systems.

Staff followed protocols to ensure they prescribed medicines safely. However, our review of patient’s records showed not all the required monitoring for some high-risk medicines, for example, an immunosuppressant medicine, had been undertaken as required. The pharmacists had identified this issue and were implementing a new process to ensure these checks would be undertaken in future.

Medicines were stored securely, although emergency medicines were stored in unlocked areas in unlocked trolleys. One emergency medicine at a branch site requiring refrigeration had not been stored appropriately. Immediately after the assessment the provider submitted evidence that improvements had been implemented. Temperatures of medicine fridges used for storing vaccines were monitored. However, records had not been consistently maintained for fridges at one branch site. We reported this to the provider and the Integrated Care Board (ICB). The provider submitted evidence to show this had been immediately reported, addressed and investigated and appropriate action taken. The learning had been shared with staff responsible for the task.

Staff regularly checked the stock levels and expiry dates for all medicines. However, stock discrepancies had been noted on the regular audits and had been reported by staff. However, no further action had been taken. The provider told us that this had been investigated immediately after the assessment and action had been taken.