Haigh Hall Medical Centre Also known as Affinity Care

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. During this focused assessment we found that the practice provided safe care and treatment for patients. During the last inspection of the service in December 2022, the provider was rated requires improvement for the provision of safe services. This was due to concerns regarding the review and monitoring of patients in receipt of high-risk medicines and medication for long term conditions, and the failure to fully action safety alerts. At this assessment we saw that the provider had made significant improvements, this included establishing processes for the review and monitoring of patients in receipt of high-risk medicines and for those with long term conditions. The provider had also put processes in place which ensured that patient safety and medicines alerts had been effectively assessed and actioned. The provider had also been making significant progress in establishing the vaccination and immunisation status of staff that were involved in the care and treatment of patients. Safety issues were managed effectively and the provider had oversight via a Quality and Safety Group which reported to the Board of Directors. We saw that the provider had developed and implemented comprehensive clinical supervision processes and that they had improved their approach to learning after incidents and significant events.

At our last assessment, we rated this key question as Requires Improvement. At this assessment, the rating has changed to Good.

This service scored 75 (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. Leaders listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. Representatives from the Patient Participation Group (PPG) felt the provider took concerns seriously and proactively made improvements to the service.

Staff told us they knew how to identify and raise significant events and incidents, and they felt that when they raised any concerns these were investigated and actions taken. Staff told us any learning was regularly shared in team meetings. Staff felt there was an open culture. The provider had processes for staff to report incidents, near misses and safety events. The whole team could access the system for reporting and were able to update incidents and learning events as the investigation progressed. This showed how incidents, concerns or learning events were recorded, actions taken and the overall outcome. We saw that in the last year there had been 46 learning events recorded, and these had either been actioned or were currently under investigation, the completed records had been shared with staff.

The provider had a Quality and Safety Group in place, which enabled them to have oversight into learning events, incidents and complaints. The Quality and safety group had quarterly meetings and reported to the Board of directors.

We saw that over the last year the provider had recorded 17 complaints, these were a mixture of verbal and written complaints. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Patients received a full response to their complaint and the practice responses included details of the Parliamentary and Health Service Ombudsman

Complaints and learning events were shared with staff when applicable and process and policies changed when needed.

The service worked with people and healthcare partners to establish and maintain safe systems of care, The provider made sure there was continuity of care, including when people moved between different services. The practice maintained policies and procedures to enable safe systems, pathways and transitions for patients.

The provider had measures in place to monitor referrals, more specifically those relating to 2-week waits. This was to ensure they kept track of the referral process and to ensure these referrals were sent quickly and without delay. Within the last 6 months they had a referral that had been sent to the incorrect provider, this had been added to their learning events and investigated with steps put in place to minimise incidents like this happening again.

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 provider had an overall safeguarding lead as well as multiple leads and deputies for each site. The staff were able to identify who their practice safeguarding leads were, they could identify concerns and were comfortable to raise these concerns.

Safeguarding policies were in place and known to staff, staff were able to locate information regarding safeguarding concerns easily. We saw evidence that all staff were appropriately trained in safeguarding and that they understood the reporting procedures. As well as online safeguarding training, the provider’s overall safeguarding lead provided bitesize learning sessions that contained case studies as well as other relevant information. They were working to identify the best ways to ensure staff were kept up to date with any changes and that they remained comfortable reporting their concerns. They evaluated all training sessions and adjusted these sessions based on staff feedback.

The practice had procedures in place to follow up any patients who failed to attend appointments. They had a dedicated team for vaccinations and immunisations to ensure everybody was contacted when required. When a parent or guardian notified the practice that they did not want their child vaccinated, they signed paperwork to confirm this, this was then noted on the patient record, this meant they would not keep receiving calls and contact from the vaccination and Immunisation team.

Safeguarding issues were regularly monitored and any concerns discussed at practice meetings. The provider took a proactive approach to safeguarding and were constantly looking at ways to improve their approach.

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 well. This equipment was checked on a regular basis to ensure all medications were in date and all equipment was working. These checks were recorded on a practice compliance portal, this portal showed when items were due to expire and when equipment had been checked, it stored the information indefinitely so the practice could identify any reoccurring issues and feedback to staff if required. All staff we spoke to were able to identify where emergency equipment and medications were kept.

Staff could recognise a deteriorating patient and knew what action to take. During their annual basic life support training, steps to take when presented with a deteriorating patient were discussed and staff trained on this. The staff were able to signal they needed help through their computer software, this would indicate to the rest of the team where help was needed.

Leaders, managers and staff reported that, in delivering care, they collaborated closely with patients to enhance their understanding and management of risks, ensuring that their needs and care decisions were more effectively addressed. The practice had a duty doctor available to support emergencies and those who had acute needs.

Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Leaders and management reported that they implemented health and safety management processes to ensure the safety and well-being of patients, staff and visitors. We received and reviewed evidence that supported these claims, this demonstrated that necessary risk assessments had been completed. We queried what happened when a risk assessment came back with recommendations or action to be completed, the provider was able to explain, and evidence changes or remedial work that had been completed.

Haigh Hall was generally in good structural condition although there was a light insert missing in the disabled toilets. Based on evidence provided and observations made during our visit, we noted that equipment was regularly maintained, serviced, stored safely and deemed suitable for use. For example, the fire extinguishers had been serviced in line with guidance.

The provider had management processes in place to ensure compliance with health, safety and well-being requirements. A Health and Safety risk assessment had been carried out in October 2024 as well as a Legionella risk assessment in June 2023. This Legionella risk assessment highlighted some remedial work to be completed; this work was carried out and we were shown evidence of the completion.

The practice was conducting regular fire drills and weekly fire alarm tests. We saw evidence of fire drills, the information provided showed details of the fire drill and what improvements the team needed to make. This information was fed back to staff in their daily huddles.

Staff had undertaken mandatory training, such as annual fire safety training. There was a business continuity plan in place which was monitored and reviewed.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The provider was currently in the process of revamping their induction and training for new starters. We were shown evidence of the new induction booklet. This comprehensive handbook included details of their supervisor and any supervision they had would be recorded here. It also showed mandatory training and a training framework that was specific to the staff member’s role. Other information included any progressions routes and an individual personalised learning plan.

We reviewed 4 staff files and found that 3 contained a record of appraisal within the last 12 months. The appraisals included development needs, training requirements and objectives for the year. The fourth staff member was currently off work but there was a plan in place for undertaking their appraisal on their return. We also checked staff vaccinations and immunisation status and found evidence of the required paperwork for 3 staff members which showed they had the required vaccinations and immunisations; the other staff member was not patient facing so their[MK1] immunisations status was not requested. However, across the practice there were still some copies of staff vaccination and immunisations missing or unavailable, the HR team were currently discussing with the medical director on what further steps could be taken. The organisation of staff files had improved since our last visit and now we were able to view all records on one platform. We did find that 1 non-clinical staff members DBS was not in line with the company policy, however a new Disclosure and Barring service check application was completed.

We also reviewed 5 staff training records and could see that staff were up to date with mandatory training.

The provider had developed processes to manage clinical supervision, their approach provided strong assurances that non-medical prescribers, newly appointed GP’s and other relevant staff received the necessary support, supervision and assessment to ensure that the care they delivered was competent, safe and effective. Additionally, a GP was available daily to ensure appropriate support and oversight.

We did not receive any feedback about people’s experiences in relation to infection, prevention and control (IPC). 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 provider had an infection prevention and control policy (IPC) in place and from staff interviews we could see that staff understood this policy. The practice had undertaken an IPC audit in September 2024 which had highlighted a few issues that required the practice’s attention the day of the assessment, the highlighted areas from the last audit had been actioned and we found the practice was clean.

During our visit we observed 4 clinical rooms, we saw the practice maintained appropriate standards of cleanliness and hygiene. There were arrangements for managing waste, and sharps bins were managed in line with current guidance.

Overall, the building was clean and tidy. The waiting room was tidy and regularly checked by team members. There were children’s toys available, however the service provided cleaning logs for these.

Staff were able to name the IPC lead and were comfortable to report any issues should they arise. Staff informed us that they were confident any concerns raised would be addressed and actioned. The provider was currently in the process of putting IPC champions in place at each of their practices. This would allow the provider to have a greater oversight. This champion would have allocated time to carry out any audits or work required.

When speaking to the reception team they were able to explain the process for handling clinical specimens and evidence that the correct procedures were followed. The provider had contracts with external companies, such as a cleaning contract, this was monitored by the management team and any issues were addressed with the cleaning company.

Staff had access to an adequate supply of personal protective equipment to carry out their roles.

We found staff received annual training on infection prevention and control and were able to access learning materials online.

Risk assessments and audits were completed, and actions taken to mitigate risks.

The service had a proactive and positive culture of safety, based on openness and honesty. Leaders listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. Representatives from the Patient Participation Group (PPG) felt the provider took concerns seriously and proactively made improvements to the service.

Staff told us they knew how to identify and raise significant events and incidents, and they felt that when they raised any concerns these were investigated and actions taken. Staff told us any learning was regularly shared in team meetings. Staff felt there was an open culture. The provider had processes for staff to report incidents, near misses and safety events. The whole team could access the system for reporting and were able to update incidents and learning events as the investigation progressed. This showed how incidents, concerns or learning events were recorded, actions taken and the overall outcome. We saw that in the last year there had been 46 learning events recorded, and these had either been actioned or were currently under investigation, the completed records had been shared with staff.

The provider had a Quality and Safety Group in place, which enabled them to have oversight into learning events, incidents and complaints. The Quality and safety group had quarterly meetings and reported to the Board of directors.

We saw that over the last year the provider had recorded 17 complaints, these were a mixture of verbal and written complaints. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Patients received a full response to their complaint and the practice responses included details of the Parliamentary and Health Service Ombudsman

Complaints and learning events were shared with staff when applicable and process and policies changed when needed.