Malvern Health 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 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 75 (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 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. The provider had processes for staff to report incidents, near misses and safety events. During staff meetings, the whole team discussed and learnt from clinical issues. Learning from incidents and complaints resulted in changes that improved care for others. For example, following a missed referral, a weekly search function was introduced that highlighted all referrals to ensure they were appropriately actioned.

The practice worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was always well managed or monitored. There were systems in place for processing information relating to new patients. We reviewed the pathology and tasks lists on the clinical system which showed they were managed in a timely way. Patient referrals to specialist services were documented in the referrals systems and patient record. These were managed promptly and appropriately followed up. Weekly searches were in place to ensure all referrals were managed in a timely manner. The practice had fail-safe systems in place to ensure all cervical cytology results were received from samples sent. They also regularly ran a search to identify patients who had cancelled their upcoming appointment for monitoring of their long-term condition. Patients were then sent another booking link or were phoned to arrange another appointment. Patients were aware of this system and told us this gave them confidence that their conditions were being appropriately monitored. A further patient told us the practice regularly informed them of their test results and provided support to help arrange hospital appointments.

The practice 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 shared concerns quickly and appropriately. The practice worked closely with the safeguarding team in the primary care network (PCN). They supported the practice to ensure all safeguarding referrals were followed up and offered further insight into safeguarding concerns which were discussed at regular meetings. Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. The practice had an effective system in place for the management, oversight and reviewing of safeguarding concerns. They maintained a list of vulnerable adults and children which was regularly reviewed and updated. Clinical system alerts were used to identify people who were at risk of harm or abuse including household contacts. Multi-disciplinary meetings were held regularly to review people at risk of harm. The practice acted on concerns and worked in partnership with other organisations. For example, they followed up children who attended AE and those that failed to attend hospital appointments.

The practice 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. The practice regularly took part in practice emergency drills to ensure staff were familiar with the emergency equipment. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

The practice detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Health and safety risk assessments had been undertaken and risks identified had been addressed. Systems were in place for the checks of fire alarms, fire extinguishers and fire evacuation procedures. Portable appliance testing was completed annually to ensure equipment was safe to use. There was a business continuity plan in place which was monitored and reviewed.

The practice made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked well together 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. There was an effective process in place to review non-medical prescribing. Appraisals were completed on a regular basis to support professional development. Staff felt supported with their professional development and we saw examples of staff developing in their role. Safe recruitment practices were followed. The practice made sure staff employed through the primary care network (PCN) were suitably experienced, competent and able to carry out their roles.

The practice 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 (IPC) lead and all staff had completed relevant training. Cleaning schedules were in place and followed. IPC audits were completed regularly, and appropriate action was taken when necessary.

The practice made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened. Staff involved people in reviews of their medicines and helped them to understand how to manage their medicines safely. As part of our assessment, a series of patient clinical record searches were undertaken by a CQC GP specialist advisor. This included a review of the management of patients on medicines that required monitoring. We found patients had received monitoring in line with guidance. Staff followed protocols to ensure they prescribed all medicines safely. Patients told us the repeat prescription system worked well, and they received timely reminders about reviews and blood tests. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines, vaccines, and controlled drugs.