Archived: Tollgate Health 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

The service did not have a proactive and positive learning culture. Managers did not investigate incidents thoroughly. Lessons were not learnt to continually identify and embed good practice. People were not protected and kept safe. Staff did not always understand and manage risks. The facilities and equipment did not always meet the needs of people, were not clean throughout, well-maintained, and risks were not consistently mitigated. There were insufficient staff with the right skills, qualifications and experience. Managers did not have effective oversight of staff training needs maintained to ensure high-quality care. Staff did not always manage medicines well and involve people in planning any changes. At our last assessment, we rated this key question as good. At this assessment, the rating has changed to inadequate. We identified breaches of regulation in relation to safe care and treatment, staffing and good governance.

This service scored 34 (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 did not have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not always investigate or report safety events. Safety concerns were not shared with staff. Lessons were not learnt to continually identify and embed good practice.

Information we reviewed demonstrated that people had opportunities to provide feedback, however we were not assured that the practice actively reviewed and followed this up consistently. Managers told us they encouraged staff to raise concerns when things went wrong, however staff were not assured that these concerns were managed appropriately. During staff meetings, we found an inconsistent and ineffective approach to learning. Staff did not feel there was an open culture, and that safety was a top priority. The provider had ineffective processes for staff to report incidents, near misses and safety events and processes to share learning were not embedded. There was an ineffective system to record and investigate complaints, and when things went wrong lessons were not routinely shared to drive improvement. We saw limited evidence of learning from incidents and complaints resulting in changes that improved care for others. Staff told us that their high workload meant that training and learning was not prioritised. This meant staff did not always have the skills and competence to make sure that they met people’s care and treatment needs.

The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

There was limited awareness of the risk to people across their care journey. The approach to identifying and managing these risks was not effective. Evidence of policies and processes about safety were limited and did not enable shared learning or drive improvement. There were delays in processing information relating to new patients due to limited staff numbers and capacity. Referrals and test results were not always managed in a timely way. We identified a significant backlog in workflow processing and no policy in place to prioritise urgent follow-up actions, for example changes to patient medicines following discharge from hospital. This meant that leaders could not be assured that staff had information which was assessed and prioritised safely, to ensure patients received the right healthcare professional or service, in an appropriate time frame. This placed patients at risk of harm.

The service did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They did not always share concerns quickly and appropriately.

Safeguarding policies were in place however staff were not always able to identify safeguarding leads. The deputy safeguarding lead had not been present in the practice since 2023 and an alternative lead had not been identified during this time. Safeguarding posters were not clearly displayed in all clinical areas. Systems to ensure staff completed safeguarding training was not effective. For example, training for the safeguarding lead had expired in November 2023. We found the practice had not ensures that all staff had received the appropriate safeguarding training and monitoring to ensure they were competent in their role. The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations. There was no named freedom to speak up guardian in place at the time of the assessment. Staff told us they did not always feel safe to raise concerns.

The service did not work well with people to understand and manage risks. They did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

During the inspection we undertook clinical record searches, and we found people had not been provided with the appropriate care and treatment and their health need were not always being met. We found that processes needed to be strengthened to manage risks and ensure effective systems were in place for regular reviews. For example, we found that people prescribed high risk medicines and for those that had long-term conditions had not always received the appropriate monitoring.

Emergency medicines and equipment did not comply with Resuscitation Council UK Quality standards. Risk assessments had not been undertaken to evidence the rationale for not stocking recommended equipment and medicine. Medicines in the practice to help manage medical emergencies were not located in a safe area. The resuscitation lead told us they did not have protected time to undertake their role. Reception staff we spoke with could not consistently describe signs to recognise a deteriorating patient or know the action to take. Patients were not always advised on risks related to their condition and actions to take if their condition deteriorated. This placed patients at risk of harm.

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.

Health and safety risk assessments had not been undertaken and risks identified. Staff told us fire drills did not take place routinely. We found some staff were out of date with fire training updates. During our onsite inspection we identified that fire exits were left ajar, the presented a security concern for the practice. There was a business continuity plan in place, however this had not been monitored, reviewed and updated. For example, the policy contained key leads who no longer worked at the practice.

The service did not 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 work 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. We found training was not up to date, learning needs and development of staff was not managed appropriately, and staff were not always working within their agreed areas of competence We found mandatory training had expired for staff in areas such as sepsis, privacy and dignity and moving and handling, staff told us they did not always have time to learn new skills and complete their training at the same time as maintaining their workload. Safe recruitment practices were not followed. Staff did not receive the support they needed to deliver safe care, this included clinical supervision and appraisals. For example we reviewed 8 recruitment files, annual appraisals were not evident for all the files we reviewed, and during the onsite inspection staff confirmed they had not received annual appraisals. The staff development policy contained a template for personal development plans, there was no evidence of the use of the development plan in the 8 files we reviewed. This meant that we were not assured that staff had the support, training, professional development, supervision and appraisals necessary for them to carry out their role and responsibilities safely.

The service did not have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not always investigate or report safety events. Safety concerns were not shared with staff. Lessons were not learnt to continually identify and embed good practice.

Information we reviewed demonstrated that people had opportunities to provide feedback, however we were not assured that the practice actively reviewed and followed this up consistently. Managers told us they encouraged staff to raise concerns when things went wrong, however staff were not assured that these concerns were managed appropriately. During staff meetings, we found an inconsistent and ineffective approach to learning. Staff did not feel there was an open culture, and that safety was a top priority. The provider had ineffective processes for staff to report incidents, near misses and safety events and processes to share learning were not embedded. There was an ineffective system to record and investigate complaints, and when things went wrong lessons were not routinely shared to drive improvement. We saw limited evidence of learning from incidents and complaints resulting in changes that improved care for others. Staff told us that their high workload meant that training and learning was not prioritised. This meant staff did not always have the skills and competence to make sure that they met people’s care and treatment needs.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

During the inspection we identified some concerns in the management of high-risk medicines, safety alerts and patient group directions (PGDs), a written instruction for the administration of medicines to groups of patients not previously prescribed for. We reviewed a sample of 4 PGDs and found issues with 3, for example an expired PGD. Staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely, but this was not always consistent. Staff employed through the Primary Care Network undertook self-directed learning and told us they had limited protected time for competency assessments on medicines optimisation at the practice. Not all staff felt confident managing the storage, administration and recording of medicines, staff had raised concerns with leaders. Staff did not have embedded systems in place to regularly checked the stock levels and expiry dates for all medicines, including emergency medicines, vaccines, and controlled drugs. The provider did not always have effective systems to manage and respond to safety alerts and medicine recalls. Staff processes to ensure people prescribed medicines with specific risks received recommended monitoring were not always effective. 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 number of antimicrobials issued by the provider was overall in line local and national averages. Staff told us there was a limited programme of regular clinical audits of prescribing that focused on improving care and treatment, however we did not see evidence of these audits. There were potential delays in prescribing due to a significant backlog in correspondence processing systems and staffing issues. The practice did not have staff competent to code patient problems, diagnosis, treatment and medicines into a coded format.