Brinsley Avenue 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 outstanding. At this assessment, the rating has changed to Good.

This service scored 63 (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. A representative from the Patient Participation Group (PPG) told us the provider took concerns seriously and proactively made improvements to the service.

Managers encouraged staff to raise concerns when things went wrong. During staff and clinical meetings, the team discussed and learnt from clinical issues. Staff felt there was an open culture, and that safety was a top priority. The provider had processes for staff to report incidents, near misses and safety events and staff were aware of these. The provider was aware they needed to implement a formal system to review trends in significant events and complaints.

There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. A system to record when a verbal response to a complaint had been given was not formally in place. Learning from incidents and complaints resulted in changes that improved care for others. For example, a blood sample bottle had been misplaced within the practice. As a result of this, the incorrect box where the bottle had been placed was removed to prevent further confusion.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. There was a transition policy in place to support this and shared care arrangements where appropriate. The provider told us how they had worked with and shared information of concern with other agencies, such as the out of hours service, regarding the abuse of a prescribed medicine by a patient. They made sure there was continuity of care. For example, the practice ran weekly searches to ensure that 2 week wait potential cancer referrals had been picked up by secondary care and acted on.

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.

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 however, they did not include reference to human trafficking or modern slavery. Following our assessment the provider updated their policy and sent it to us. Staff were aware of how to access the safeguarding policy and were appropriately trained in safeguarding procedures.

The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations. They discussed people with safeguarding concerns at clinical meetings and had risk assessed the frequency in which they reviewed their safeguarding lists. They attended safeguarding meetings with the local authority when requested to do so. Whilst the service corroborated safeguarding lists with the palliative care service and care homes, attempts to engage with the wider multi-disciplinary teams, such as health visitors and social workers, remained unreciprocated. Alerts were added to patients’ records when there was a known safeguarding concern. We found that alerts were not always added to the records of people living in the same household. Before the end of our assessment, the provider sent us a policy to address this and details of the actions taken.

There were systems in place to follow up people who frequently attended AE and children who failed to attend secondary care or childhood immunisation appointments.

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. Staff had received training on sepsis and cardiopulmonary resuscitation to support them in this. People were advised on risks related to their condition and the actions to take if their condition deteriorated. Staff gave an example of how a non-clinical member of staff had identified a rapidly deteriorating person in the waiting room and called for clinical help. Following a hospital admission, the person made a full recovery. The service raised this as a significant event which highlighted the positive outcome of their processes and the actions taken.

There were appropriate emergency equipment and medicines and where emergency medicines were not available, risk assessments had been completed.

The service mostly detected and controlled potential risks in the care environment. Annual fire risk safety drills were carried out by trained fire marshals and learning was shared with staff. For example, the importance of signing in and out of the building on the staff board. They made sure equipment, facilities and technology supported the delivery of safe care.

Contracts were in place to ensure the premises were maintained. A risk assessment had been completed for the storage of oxygen within the practice. There was a business continuity plan in place which was monitored and reviewed. The continuity plan was discussed and reviewed at staff meetings.

Weekly fire alarm checks were completed however, records of this had not been maintained. Following our assessment, the provider sent us a log of when these had been carried out. Health and safety risk assessments and audits had been undertaken. We reviewed the legionella risk assessment and found that all the required actions had not been carried out. Following our assessment, the provider sent us a checklist to record when the water temperatures were checked and that they were within the required temperature limits. Blind hoops were not always secured in line with national alerts. Following our assessment, the provider sent us evidence that these had been purchased

Following our assessment the provider sent us evidence of checks for gas, calibration of equipment and emergency lighting.

The service had systems in place to ensure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. For example, they had increased clinical staffing hours prior to a staff member's planned absence from work. They worked together well to provide safe care that met people’s individual needs.

There were a range of clinical and non-clinical roles within the practice. Systems were in place to audit the prescribing of non-medical prescribers and learning was shared with them through clinical supervision. We found training was up to date, learning needs and development of staff was managed appropriately, and staff worked within their agreed areas of competence. Systems were in place to recognise and manage poor performance.

Some staff appraisals had not been completed. There was a plan in place to complete this, and the risk register had been updated to reflect this.

Safe recruitment practices were mostly in place. However, reassurance that staff employed by the Primary Care Network and working in the practice had been recruited, trained and supported to carry out their role were not in place. Following our assessment the provider sent us a memorandum of understanding to demonstrated how the host practice did this. Of the 4 staff files we reviewed, we found that 2 had not received an assessment to review their physical and mental health to determine if reasonable adjustments were required to support staff in their role. Following our assessment, the provider sent us a health questionnaire they had implemented to assess staff health needs.

The service did not always assess and manage the risk of infection. Systems were not always in place to detect and control the risk of it spreading.

Infection prevention and control (IPC) audits had been completed for both practices, however they failed to identify overflows in sinks and a lack of face masks within the practice. Where risks had been identified, action plans to mitigate the risks and monitor progress were not in place. For example, the cleaning of carpets in non-clinical areas and several non-wipeable seats in clinical rooms. Following our assessment, the practice sent us evidence they had either taken action to address the risks or, updated their risk register to mitigate risks identified through the IPC audits.

Staff immunisations to potential health care acquired infections were not up to date and risk assessments had not been completed to mitigate potential risks. Following our assessment, the provider put in place a health questionnaire to gather this information.

Mops were not always stored correctly. There were colour coded mops for designated areas within the building. We found that mop heads were touching increasing the risk of cross-contamination. Following our assessment, the provider added this to their risk log and addressed it with the cleaning company. They planned weekly checks to ensure this did not happen again. Completed cleaning schedules for cleaners were not in place. The provider told us they would address this with the leaning company. Cleaning schedules for clinical staff were put in place before the end of our on-site assessment. Control of Substances Hazardous to Health Regulations (COSHH) risk assessments were available for cleaners.

The practice had a designated IPC lead and all staff had received relevant training. Spill kits for bodily fluids were in place and staff were provided with training on their use.

The service mostly 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 understand how to manage their medicines safely. However, we found that medicine reviews lacked detail although they were coded. The provider updated their medicine policy to ensure that more details were recorded in patients’ records.

People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms. Staff received regular training, were competency assessed on medicines optimisation, and felt confident managing the storage, administration and recording of medicines.

Staff managed prescription stationery appropriately and securely. Staff followed protocols to ensure they prescribed medicines safely.

Staff followed established processes to ensure people prescribed medicines with specific risks received the recommended monitoring. However, these systems were not always effective. For example, our remote searches identified 69 people prescribed a medicine used in the treatment of high blood pressure who had potentially not received the required monitoring. There was evidence they had all been recalled for the required tests but people had not attended. Following our assessment, the practice updated their processes and policy to include the introduction of shorter prescription times to ensure people attended for the monitoring. At our onsite visit, we found that action had been taken for all the people identified and that the number had reduced to 65 people over a few days. Systems to follow up people prescribed a medicine for the treatment of hypothyroidism had also been put in place and actioned.

Medicines were stored securely and at appropriate temperatures, daily temperature checks of fridges confirmed this. However, there were no systems in place to continuously record the temperature of the fridges. Following our assessment, the provider sent us evidence that data loggers had been purchased to enable this. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines.

Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments. The provider had effective systems to manage and respond to safety alerts and medicine recalls. Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. Prescribing data reviewed as part of our assessment confirmed this. For example, the prescribing of broad-spectrum antibiotics was below the national average.

There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.