Kidderminster Medical 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.We rated this key question as Good.

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 practice had a good learning culture, and processes were in place to support staff to report incidents, near misses and safety events. Managers investigated incidents thoroughly. Learning from incidents and complaints was discussed in meetings and resulted in changes that improved the service.

Leaders were committed to learning, and we discussed some examples of significant events and the actions the practice had taken in response to the learning identified. One incident involved a power failure to the clinical refrigerator. In response to this, the practice purchased an intelligent plug socket for the refrigerator to identify when there is a power outage to the socket via a notification to a smart device.

A second example related to a child vaccination error where a child had been over vaccinated. Staff reported that the learning from this incident included not providing vaccinations without the ‘Red Book.’ (This book contains a record of a child's immunisations and vaccinations). In addition, the practice arranged for two nurses to work together for vaccinations and immunisations and for both nurses to sign off the administration of these medicines.

The practice worked with patients and healthcare partners to establish and maintain safe systems of care. Staff worked to facilitate continuity of care, including when patients moved between services. There were protocols in place for managing incoming correspondence into the patient’s medical records.

Patient referrals to specialist services were documented in the referrals systems and patient record. The Wyre Forest Health Partnership had a ‘Quality, Performance and Risk Committee’ in place and as part of that remit, referral rates were actively monitored for all of their practices. We found patient referrals were managed in a timely manner however, staff reported difficulties keeping up with the workload on the current staff workforce size.

Safeguarding policies and procedures were in place to keep people safe and safeguarded from abuse. The practice had a nominated GP safeguarding lead and a Safeguarding Administrator. Staff had completed the relevant safeguarding training for their role and shared concerns quickly and appropriately. Leaders told us staff were aware that safeguarding was everyone’s responsibility. We saw safeguarding posters located in various places around the practice to promote safeguarding and clarify the systems in place.

The practice maintained a list of vulnerable adults and children and acted on concerns working in partnership with other organisations. Clinical system alerts were used to identify people who were at risk of harm or abuse including household contacts. There were systems in place to respond to concerns and act on correspondence. For example, they followed up children who failed to attend their appointments or were frequent attenders to the accident and emergency department.

Safeguarding was discussed regularly as part of monthly clinical meetings. Safeguarding cases were also discussed at Wyre Forest Health Partnership meetings where safeguarding risks and patient care was reviewed. Leaders told us they also discussed complex safeguarding cases directly with the Integrated Care Board Head of Safeguarding for Adults and Children where necessary.

Staff could recognise a deteriorating patient and knew what action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated. There were processes in place to ensure care was prioritised for the most clinically vulnerable patients.

Emergency equipment was available and maintained. Systems were in place to check the emergency equipment and medicines regularly. However, we found adrenaline medicine was not located within all of the consultation rooms where vaccines were administered to patients. The Resuscitation Council UK states it is good practice to keep adrenaline 1mg in 1ml ampoules for intramuscular use for the treatment of anaphylaxis in an 'anaphylaxis pack' and adrenaline (usually 1mg in 10ml) for the treatment of cardiac arrest in a separate cardiac arrest drug pack. This is to prevent adrenaline route and dosing errors during the treatment of anaphylaxis.

The practice facilities were fully accessible to patients. Consultation rooms were available on the ground floor and lifts provided access to other floors.

The practice detected and controlled potential risks. They made sure equipment, facilities and technology supported the delivery of safe care. Contracts were in place to ensure the premises were maintained. 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. The practice provided us with evidence of health and safety risk assessments which showed that risks were properly managed.

There was a business continuity plan in place which was monitored and reviewed. As part of the Wyre Forest Health Partnership, Kidderminster Medical Centre had access to the various practice sites and could receive assistance from colleagues from across these sites, which enhanced their business continuity preparedness.

The practice made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. Leaders were supportive of staff developing their skills and there was an apprenticeship programme in place.

There were a range of clinical and non-clinical roles within the practice. GPs had also been nominated to lead on clinical areas such as drug and alcohol addictions; respiratory medicine; women’s health; and research.

We found learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence. Leaders explained they had a mentoring system in place for clinical staff. Every employed clinician was assigned a mentor, and mentoring sessions were arranged to share cases and develop in areas of clinical interest. We saw evidence of clinical supervision and mentoring sessions.

In addition, for clinicians who are prescribers, a prescribing tutorial was arranged every 3 months. At least 6 recent prescriptions were reviewed to determine if prescribing was in line with local and national guidance.

On an annual basis the Wyre Forest Health Partnership arranged away days for clinical staff for teaching sessions.

As part of our assessment, we reviewed staff personnel files and training records. We found safe recruitment practices were followed and appropriate checks had been completed. In addition, staff had completed necessary training according to their roles within the practice.

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 an infection control policy in place and a designated infection, prevention and control (IPC) lead. Staff had completed relevant infection control training. Risk assessments and audits were completed, and actions taken to mitigate risks. Clinical waste procedures were in place. The practice had effective oversight of the external cleaning company to ensure cleaning schedules were followed and cleanliness met the required standard.

The practice strived to make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved patients in planning, including when changes happened.

Staff involved patients in reviews of their medicines and helped them understand how to manage their medicines safely. Patients knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms.

Medicines were stored securely and at appropriate temperatures. Refrigerators used to store vaccines and medicines were monitored to ensure temperatures were maintained and products were appropriately stored within them. Staff regularly checked stock levels and expiry dates for all medicines, including emergency medicines. There were Patient Group Directions (written instructions to help specific healthcare professionals supply or administer medicines to patients)in place which relevant staff worked to.

There was a programme of regular clinical audits of prescribing that focused on improving care and treatment. We discussed with staff an audit which had been undertaken on hormone replacement therapy (drugs used to treat the menopause), where the audit assessed the prescribing of both oestrogen and progestogen medicines for patients.

Prescribing data was reviewed as part of our assessment found practice performance was in line with national averages for Pregabalin and Gabapentin medicines (primarily anticonvulsant drugs, also prescribed for pain), and antibiotics. The practice performance for the prescribing of multiple psychotropic medicines (used to treat various mental health conditions) was slightly above the national average.

As part of our assessment a Care Quality Commission GP Specialist Advisor undertook searches of patient records on the practice’s clinical system. Our clinical records review identified the following:

Azathioprine (a drug used to treat rheumatoid arthritis): We identified 19 patients prescribed this medicine and found no issues with the monitoring being provided for them.

Direct oral anticoagulants(DOACs) (blood-thinning medications): We identified 409 patients were prescribed these medicines of which 20 had potentially not received the required monitoring. We reviewed in detail the care records of 5 of these patients and found all 5 patients had been short-scripted their medication to ensure they received the necessary blood tests and weight checks before being issued their next prescription.

Bisphosphonate (medicines that strengthen bones): National guidance recommends that after a patient has been taking this oral medicine for 5 years, the need for continuing treatment should be reassessed and consideration should be given to providing a Dual‑Energy X‑ray Absorptiometry (DEXA) scan. DEXA scanning offers a non‑invasive and highly accurate method for evaluating body composition, including bone mineral density. We identified 57 patients who had been prescribed this medicine for over 5 years and reviewed the records of 5 patients. We found 2 patients out of 5 were overdue a DEXA scan, of which 1 patient had a DEXA scan appointment already booked.

Safety Alerts: There was a process in place for recording and sharing medicine safety alerts. Safety alerts were discussed in clinical meetings. We reviewed patients who were prescribed both an Aldosterone antagonist (a diuretic medicine which prevents potassium loss) and an Angiotensin-converting-enzyme (ACE) Inhibitor (a drug used primarily for the treatment of high blood pressure and heart failure). We identified a total of 85 patients prescribed these medicines and found 6 patients who were overdue monitoring. We looked in detail at 5 of these patient records and found 3 patients were overdue monitoring by just 3 weeks or less; 1 patient was no longer prescribed these medicines; and 1 patient had already been booked an appointment.

Medication reviews: We reviewed a random sample of 5 medication reviews out of a total of 3061 reviews that had been completed for patients in the previous 3 months. We found no issues with any of these medication reviews and found they had been appropriately coded and contained necessary information.

As part of our assessment, we reviewed the processes in place for controlled drugs. Controlled drugs are medicines that are regulated by the government. This is usually because they are at higher risk of causing harm (such as dependence or misuse). Systems and processes included prescriptions not being issued on repeat; no more than 28 days of medicine prescribing; regular patient reviews; dedicated text messages to patients with information about the risks and monitoring required; and a proactive approach to offering patients the opportunity to reduce their medication.