The Heron 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.

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.

The service demonstrated a proactive and positive culture of safety based on openness and honesty. Staff were encouraged to report incidents, concerns and complaints through established governance systems, including an electronic incident reporting system. Incidents and complaints were investigated and discussed at regular meetings, with learning shared across staff groups to support continuous improvement.

Staff described examples where reflective learning followed significant events. Following an on-site incident involving a distressed patient, leaders reviewed the response, considered the impact on patients and staff, provided wellbeing support and held a team debrief. Learning identified actions to strengthen responses to similar situations in future. The practice also demonstrated compliance with the duty of candour, including promptly informing and apologising to patients when errors occurred and using events as opportunities for shared learning. Training, supervision and weekly clinical meetings supported a learning culture across the organisation.

Representatives from the Patient Participation Group (PPG) felt the provider took concerns seriously and proactively made improvements to the service.

The service worked with people and healthcare partners to establish and maintain safe systems of care. Arrangements supported continuity of care when patients moved between services and ensured information was communicated appropriately across pathways.

The service used digital systems to support safe triage and care navigation. All online requests were clinically triaged by a GP partner and managed through a protocol which prioritised urgent presentations on the same day. Staff supported patients who were unable to access online systems by completing requests on their behalf. Referrals, transitions and shared care arrangements were monitored through established processes and collaboration with external providers. Examples included structured management of patients with ADHD transitioning between child and adult services, regular liaison with community psychiatry teams and agreed arrangements to share responsibility for ongoing monitoring. Laboratory results and correspondence were subject to defined timescales, oversight processes and escalation procedures. Community nurses and other multidisciplinary professionals worked closely with the practice to facilitate coordinated care.

There were systems in place for processing information relating to new patients.

The service worked with people and partner organisations to understand and promote safety whilst protecting people from abuse, neglect and avoidable harm. Safeguarding arrangements were embedded within routine practice activity.

There was a named safeguarding lead supported by multidisciplinary processes and regular safeguarding meetings. Vulnerable children and adults were identified through coding systems and alerts on patient records. The practice maintained safeguarding registers and undertook routine searches to identify vulnerable patients requiring review. Monthly safeguarding meetings involved a range of professionals, including health visitors, midwives, district nurses, pharmacists and community teams. Protected time was allocated to safeguarding leadership activities, including follow up actions and record management. Staff training was monitored through the service’s electronic monitoring learning management system and concerns were shared appropriately with partner agencies.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures.

The practice worked with people to understand and manage risks and provided care that was safe and supportive. Systems were in place to identify patients whose needs required urgent intervention.Patients could access support through online clinical requests, telephone contact and face-to-face routes. Triage processes enabled clinicians to identify deteriorating or acutely unwell patients promptly, with urgent appointments available daily. The practice employed paramedic support and worked with community teams to respond to urgent needs. We found that the required emergency equipment and medicines were available and subject to appropriate checks. However, emergency equipment was stored across five separate locations on the ground floor, which could affect timely access in an emergency. Immediately following the inspection, the provider submitted evidence demonstrating that emergency equipment and medicines had been relocated and were subsequently stored together in a single location.Staff completed annual emergency and resuscitation training and were aware of emergency protocols. Patients received safety-netting advice and information about what to do if their condition deteriorated.

The service identified and controlled risks within the care environment and ensured facilities and equipment supported the delivery of safe care.Fire safety arrangements were established, including weekly fire alarm testing, trained fire wardens and regular fire drills. Safety alerts relating to premises and equipment were distributed promptly and actions were documented. The service maintained a business continuity plan that was reviewed regularly and updated when staffing or supplier arrangements changed.

The service ensured there were sufficient qualified, skilled and experienced staff who received support, supervision and development opportunities.

There was a structured approach to induction, supervision, appraisal and competency assessment for clinical and non-clinical staff. Clinical staff had access to mentors, protected supervision time, consultation audits and regular meetings. Physician associates worked under supervised arrangements with documented oversight. The practice operated as a training practice and supported a range of professional development opportunities. Staff training compliance was monitored through electronic systems and recruitment arrangements included regular audits of personnel records. Leaders monitored performance and provided additional support, coaching and training where required. Staff reported access to learning opportunities and described a supportive working environment.

The practice assessed and managed infection prevention and control risks and took action to minimise the risk of infection transmission.A named IPC lead oversaw policies, audits and monitoring activities. Monthly clinical room audits were completed using a checklist and findings were addressed promptly. Recent audits identified minor issues relating to sharps management and room organisation, and staff were reminded of expected standards. Staff completed IPC training and the practice had introduced a more detailed room-by-room audit process to strengthen oversight. Cleaning, monitoring and governance arrangements supported a safe environment for patients and staff.

The service had effective arrangements for the safe management of medicines. Staff were trained and competent, responded appropriately to medicines safety alerts, and undertook regular audits to support safe and appropriate prescribing. Antibiotic prescribing was prudent compared with local and national averages, and monitoring for most high‑risk medicines was generally effective.

A GP specialist adviser reviewed agreed clinical searches. These showed strong performance in several areas, including excellent monitoring of DMARDs and generally good oversight of patients prescribed DOACs, warfarin, ACE inhibitors and angiotensin receptor blockers. Monitoring arrangements for patients with hypothyroidism, asthma and chronic kidney disease were also broadly effective.Searches identified a number of areas where follow‑up and monitoring could be strengthened. Around half of patients prescribed lithium had at least one overdue monitoring requirement, although records showed recent reminders had been sent and follow‑up appointments booked. Some patients prescribed aldosterone antagonists and combinations of medicines highlighted through MHRA alerts had monitoring recorded outside recommended timeframes, though most had received recent reminders and were not significantly overdue. A small number of patients prescribed gabapentinoids had not had a documented review within the past year.

The main area for improvement related to ongoing follow‑up for patients with poorly controlled diabetes. Searches identified several patients with significantly elevated HbA1c levels where initial action had been taken but continued follow‑up was not always timely. The practice has since provided evidence of active recall, booked blood tests, and planned reviews for these patients, demonstrating responsive action once gaps were identified.

Staff managed medicines safely, including the storage and disposal of medicines, vaccines, controlled drugs and medical gases. Stock checks were completed regularly, and waste medicines were disposed of appropriately. Clinical audits were used to support safe prescribing and continuous improvement.

Overall, medicines optimisation processes were effective and supported safe prescribing and monitoring. The service demonstrated strong performance across most areas reviewed, with opportunities to strengthen ongoing follow‑up for patients with poorly controlled diabetes and improve monitoring compliance for a small number of patients prescribed high‑risk medicines.