Tramways Medical Centre - O'Connell Also known as Tramways Medical Centre (Dr J O'Connell & Partners)

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 staff protected people from avoidable harm and made sure care was delivered from environments that were clean and well maintained. At our last assessment, we rated this key question as good. At this assessment, the rating has changed to requires improvement.

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.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

The service did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

We saw that a few clinical rooms had no lockable doors. Some of these rooms contained clinical refrigerators, medicines and sharps. This compromised effective medicines’ management and put staff and patients at risk.

There were some concerns about the arrangements for managing fire risks. The practice’s fire risk assessment was out of date and had not been reviewed. As a result of a recent fire evacuation drill, it was discovered that the fire alarm system was not audible of the first-floor administrative area of the premises. The provider told us that this was due to be fixed as a matter of urgency. Fire extinguishers were installed and had been serviced in December 2026. Out of 26 staff, 5 staff were not up to date with mandatory fire training. Electrical appliance testing was also overdue for all items on the practice’s inventory.

The service had contracts to ensure the premises was maintained. Staff and leaders had not completed health and safety risk assessments or undertaken audits to ensure they had identified and addressed all risks. The service had a business continuity plan which outlined how the service should continue to operate in the event of a disruption, but a hard copy was not kept offsite which would have provided contingency in such an event.

We saw that an NHS Smartcard (a physical, chip-based ID token used by healthcare staff to securely access clinical records and national systems like the Electronic Prescription Service) was left unsecured in a clinical storage trolley in an unlocked room. This posed a risk of unauthorised data access and identity confusion.

The service did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

The service employed a range of clinical and non-clinical roles, which included GPs, nurses, paramedics and pharmacists. Leaders lacked oversight as to whether staff were up to date with their training which the service had deemed mandatory and that they were operating within their agreed areas of competence. The service could not demonstrate that it followed safe recruitment procedures when employing staff, which were in line with national legislation. This included identity checks, review of qualifications, obtaining of professional references and a criminal records check. Some staff had a disclosure and barring check, but some did not, and there was no risk assessment undertaken to explain the absence of such checks. There was no consistent process for renewing staff DBS checks, and some staff members had not had one obtained for more than 4 years. Following our inspection the provider told us that GP recruitment files were held centrally in the practice but they were not made available to us on the day of our inspection.

There was an induction/competency checklist for all of the staff files that we reviewed. These had not been completed or signed off in full in any of the examples that we reviewed. There were no records of clinical supervision documented. There was no system to ensure that appraisals and one-to-ones were carried out regularly. In one instance we saw that a clinician had been onboarded and had signed their employment contract and were on the rota before disclosure and barring checks and references had been secured, or induction commenced.

There were no recruitment files available for any GPs. When we spoke to the provider about this, we were told that they keep their own files in their possession. This created the potential to impact on the oversight of safe staffing because it conflicted with data accountability.

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The service had cleaning schedules available, which outlined how the cleaning team staff should clean the building. This schedule had been developed by the cleaning company employed by the practice. We did not see this type of schedule mirrored for practice staff, to ensure that rooms and clinical equipment were cleaned between patients. During our onsite visit, the service's premises and a sample of equipment reviewed was noted to be reasonably clean. There were some issues with dust which had been highlighted by an audit carried out by the cleaning company however and some rooms were cluttered. We saw that a few bins did not have any type of lid and some with lids were not foot-operated in line with best practice for non-touch techniques. The practice had recently ordered wall mounting equipment for hand sanitisers. The provider had acknowledged that the fabric of the chairs in the waiting area was beginning to disintegrate and posed a risk of infection.

The service’s infection prevention and control lead told us they conducted regular risk assessments and audits to ensure compliance and took action where necessary to mitigate any identified risks. However, there was no timescale for completion and no indication of the severity of the risks attached to these audit findings. There was no indication of who was responsible or most appropriate for completing the action. Most staff had completed relevant training in infection prevention and control, with a few gaps. There was no protected time for the infection prevention and control lead, above their usual clinical duties and clinical administration time, to afford time to the role, which increased pressure.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.