Oldfield Surgery

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 Requires Improvement. At this assessment, the rating has changed to Good.

This service scored 69 (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.

The service promoted an open and positive safety culture. People and staff felt supported to raise concerns, and leaders encouraged learning when things went wrong. Incidents, near misses and complaints were reported, investigated and discussed at team meetings. Learning points and actions were shared to improve care. Staff apologised and offered support when mistakes occurred, and changes were made to prevent recurrence. For example, in response to an incident, the service had moved from requiring people to arrange their own Prostate-Specific Antigen (PSA) blood tests to a system where the service contacted people when tests were due. This means people did not have to remember themselves, and it helped make sure tests happened on time. If someone did not respond, staff followed up and worked with their named GP or hospital to ensure people received tests in a timely way in line with national guidance.

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.

The service had systems to support safe care and treatment. Staff followed clear pathways for referrals, test results and follow-up. People experienced smooth transitions between services, and staff worked with other professionals to coordinate care. Processes for monitoring recalls and immunisation uptake were in place and regularly audited to reduce risk.

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.

The service had safeguarding arrangements that were understood and followed by staff. Staff were trained in safeguarding procedures and could clearly explain how they would raise a concern. There were posters in clinical and treatment rooms showing who to contact if a safeguarding concern was identified. The service had a designated safeguarding lead and a safeguarding administrator who kept an up-to-date list of vulnerable people and acted promptly on concerns. They worked in partnership with other organisations to protect people from harm.

Staff told us they share information through secure systems and regular meetings. External partners confirmed the service responds promptly to referrals and safeguarding queries.

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.

The service had safeguarding arrangements that were understood and followed by staff. Staff were trained in safeguarding procedures and could clearly explain how they would raise a concern. There were posters in clinical and treatment rooms showing who to contact if a safeguarding concern was identified. The service had a designated safeguarding lead and a safeguarding administrator who kept an up-to-date list of vulnerable people and acted promptly on concerns. They worked in partnership with other organisations to protect people from harm.

Staff told us they share information through secure systems and regular meetings. External partners confirmed the service responds promptly to referrals and safeguarding queries.

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

The service did not consistently maintain a safe environment. The service’s health and safety policy was more than a year out of date, and had no version history, so it was unclear when it had last been reviewed. Staff could not find the Health and Safety Policy when asked. Leaders addressed this and updated the policy and made it available to all staff by placing it on a notice board in the main office and putting it on their intranet on the day of inspection. The Health and Safety Law poster was on the wall but had not been filled in with the name of the person responsible. Staff completed this straight away during our onsite visit.

The Control of Substances Hazardous to Health (COSHH) paperwork for oxygen had not been reviewed since 2017, but once this was highlighted, the service took steps to review it. The cleaner’s cupboard was away from people using the service in a locked room but was not signposted for hazardous substances. The service acted immediately to resolve this during our onsite visit.

However, the service had addressed other risks in relation to the service environment. For example, asbestos warning stickers were applied to ceilings to prevent accidental disturbance. Fire safety procedures were in place, with alarms, extinguishers, and evacuation signage, and staff understood emergency arrangements. A business continuity plan was available and reviewed regularly, and facilities and equipment supported staff to deliver safe care.

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.

Not all recruitment checks were carried out in accordance with Schedule 3 requirements of the Health and Social Care Act 2008. We reviewed a sample of 5 staff files and noted that not all records contained the required information, for example, a full employment history, references, and documentation of supervisions. We fed this back to the service, who addressed this immediately and provided assurances that recruitment files would be reviewed and brought in line with their current policy.

Since our feedback, the service implemented a full review of all HR files to ensure consistency and compliance. Updated forms are now used for all new staff, and induction plans for all roles are routinely added to HR files. A centralised spreadsheet has been introduced to track compliance against HR requirements for every staff member.

Disclosure and Barring Service (DBS) checks were carried out before staff started at the service. Training, deemed as mandatory by the service, was monitored through a central matrix, and staff were supported with protected time for learning. Appraisals were completed annually, and clinical supervision was embedded for clinical roles to maintain competence. Where gaps were identified, such as overdue training, leaders acted promptly to address them.

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 service had an infection prevention and control (IPC) lead and they ensured staff received appropriate training. Staff completed IPC workbooks and attended face-to-face sessions, including practical hand hygiene training. Compliance with good hand hygiene measures was monitored through regular audits. Regular reminders were issued about being “bare below the elbows” and avoiding nail polish or extensions to reduce the risk of spreading germs and infection.

Up-to-date IPC policies were available, and the service had an isolation room in case of suspected infections. Staff could also explain correct isolation procedures. IPC risk assessments and audits were completed with clear action plans, such as scheduling additional training for staff who missed sessions and reinforcing aseptic technique standards during clinical supervision. Staff used personal protective equipment (PPE) which met recommended national guidance and was appropriate for the services they were delivering and the level of infection risk.

The service made sure medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

Governance and audit arrangements for the oversight of medicines were in place and effective. Remote clinical searches conducted as part of this assessment showed people prescribed high-risk medicines were being monitored and reviewed in line with national guidance. For example, people prescribed methotrexate had monitoring checks recorded for full blood count, liver and kidney function, and prescriptions included the day of the week to reduce risk of overdose. Alerts were visible in people’s records, and shared care protocols were documented. People receiving Disease‑Modifying Anti‑Rheumatic Drugs (DMARDs), ACE inhibitors, and other medicines requiring monitoring had blood tests completed within recommended timeframes, and clinicians checked results before issuing prescriptions. Where monitoring was overdue, records showed actions were being taken by the service, such as chasing blood tests and documenting follow-ups. Medicines reviews were coded correctly and included checks on monitoring and dosages, ensuring compliance with national guidance.

During our on-site visit, we noted Patient Group Directions (PGDs) and Patient Specific Directions (PSDs) were completed appropriately, and being followed by relevant staff. (A PGD is a written instruction that allows certain healthcare professionals, such as nurses, to administer specific medicines to people without needing a prescription for each person. A PSD is a written instruction from a prescriber for a named person, telling staff exactly which medicine to give and how). Staff were able to demonstrate which medicines could be administered by a nurse, nursing associate or healthcare assistant.

The service held suitable emergency equipment and medicines, and risk assessments were completed for recommended emergency medicines not held on site. Medicines were stored securely and in line with current best practice guidance. Fridge temperature records for vaccine storage were maintained, and any temperature variances were logged and addressed. Staff understood how to respond to a cold chain breach and provided evidence of this.

Leaders demonstrated an effective system for acting on safety alerts. Our remote clinical searches showed people affected by alerts were contacted and their care and treatment reviewed in line with guidance. Medicine reviews were embedded into clinical supervision and appraisal processes, supporting continuous improvement. Oversight was strengthened through regular audits and monitoring, which ensured timely reviews for people on high-risk medicines.

However, during the onsite visit, there was no effective system for managing or securing prescription stationery. Blank prescriptions were stored in the main office and locked away but without a log or tracking process, increasing the risk of theft and potential misuse. This was not in line with national guidance. On the day of inspection, the service immediately produced a form to track prescriptions and created a standard operating procedure to improve the way it monitored the security of blank prescriptions.