The Acocks Green 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.

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. We saw that team meetings for all staff were regularly held including clinical and non-clinical, where staff had the opportunity to feedback any concerns or good practice. Staff told us they found these meetings helpful in receiving support.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. Managers encouraged staff to raise concerns when things went wrong. The provider had processes for staff to report incidents, near misses and safety events. Staff had confidence in leaders to ensure that incidents were managed well.

There were three significant events recorded in the previous 12 months, and the provider had systems in place to review these as part of an annual significant event analysis (SEA) review. Alongside the wider partnership at Health and Beyond, they used comprehensive analysis to recognise trends or themes. Those we sampled had been reviewed, analysed and shared in line with policy. Significant events were discussed with staff to enable actions to improve patient safety, quality of care, and operational effectiveness. We saw that when an error had been made in medicines, the provider discussed the concern within the clinical group as well as the wider partnership to minimise risk of reoccurrence. Staff were offered time to reflect and consider additional learning.

There was a system to record and investigate complaints. Information reviewed demonstrated that people had opportunities to provide feedback, and they knew how to make a complaint. Lessons were learnt from individual complaints and shared with the practice team to improve the quality of care. Feedback and information was available in the practice and on their website

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.

There were systems in place for processing information relating to new people. The service worked with other providers to deliver shared care and when people moved between services. We found systems were in place to ensure referrals and test results were managed in a timely way.

We saw that people who had received care in hospital had follow up appointments and medicines reviews. There was a range of structured meetings in place including full team meetings, clinical meetings and wider organisational meetings. These meetings were used to support safe systems by facilitating discussion and oversight of safeguarding, palliative care, and clinical and operational matters.

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 and understood by staff, all of whom were appropriately trained in safeguarding procedures. Staff had access to a designated safeguarding lead for adults and children. The practice maintained a register of vulnerable individuals, and we saw registers were routinely reviewed and relevant information was shared effectively within the team. Staff responded proactively to concerns, implementing actions and learning in collaboration with partner organisations such as during multi-disciplinary team meetings and panels.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that were safe, supportive and enabled people to do the things that mattered to them.

People told us that they received advice regarding how to manage their conditions. An example was a person with diabetes told us that they had visited the social prescriber who had advised on exercise and made suggestions about further help they could receive such as referrals into the podiatry service.

Emergency equipment was available and maintained, and staff could recognise a deteriorating patient and knew of action to take. They were trained in sepsis awareness, anaphylaxis, cardiopulmonary resuscitation (CPR), and basic life support training. People were advised on risks related to their condition and actions to take if their condition deteriorated.

Reception and administrative staff who handled calls to the practice and arranged appointments with the clinical team were aware of potential red flag symptoms. They knew when to notify a GP or other clinicians with concerns about a patient who may be acutely unwell and/or deteriorating. Staff had been provided with training in health and safety related topics such as fire safety, basic life support and resuscitation training.

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

Contracts were in place to ensure the premises were maintained. Health and safety risk assessments and audits had been undertaken. There were some gaps in the management of the care environment, as not all risks had been identified through existing audit processes. For example, a missing emergency pull cord in an accessible toilet had not been detected, although this was addressed promptly by the provider once identified.

The premises were clean and in reasonable condition. 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.

There were a range of clinical and non-clinical roles within the practice. We found training for permanent staff was up to date, learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence. Safe recruitment practices were followed.

However, there were some gaps in recruitment oversight and training monitoring, as systems to verify the training records of temporary and locum staff were not fully embedded. This meant key training, such as safeguarding, was not always assured prior to staff commencing work, although this was addressed promptly following the inspection.

The service did not always assess and manage the risk of infection. They did not always detect and control the risk of it spreading. However, they shared concerns with appropriate agencies promptly.

The practice had a designated infection, prevention and control (IPC) lead and all staff had had relevant training. Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks. All staff had the appropriate immunisations to safely manage spills and training around spills was part of the IPC training.

However, we found that the provider did not have a record of immunisation history, including Hepatitis B vaccine immunity for locum staff. This could put staff at risk of harm when handling bodily fluid samples or spills. Following the on-site inspection the provider confirmed that the locum staff policy would ensure that immunisation and vaccination was checked when employing temporary staff. The provider has informed us that since the inspection, they had immunised all staff and boosters provided where appropriate.

Although action has been taken these revised arrangements need to be fully embedded into practice and operating effectively to support and maintain good infection prevention and control procedures.

The service 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. 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 all medicines safely, and ensured people received all recommended medicines reviews and monitoring. Medicines including controlled drugs were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines, vaccines, and controlled drugs. Waste medicines were recorded and disposed of appropriately including medicines returned by people. 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 followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring. 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 similar to local and national averages. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.

However, we found that the service did not hold Naloxone (a medicine used to reverse the effects of a suspected drug overdose) within its emergency medicines kit. Managers had not fully considered that this medicine may be required not only in clinics where opioid (strong pain relief medicine that needs monitoring due to potential risks) treatment medicines are prescribed, but also in other emergency situations where there is a risk of drug overdose. The provider was proactive in understanding and managing our concern and immediately obtained Naloxone as part of the routine emergency medicines held by the service.

As part of our inspection, our GP Specialist Adviser carried out remote searches of clinical records to check how the practice monitored patients’ health in relation to the use of high-risk medicines.

We found that medication reviews were completed, people on high-risk medicines had received appropriate monitoring, and that prescribing was safe.

The clinical searches identified 245 people who had hypothyrodism (underactive thyroid). Of these people 4 did not have Thyroid Function Tests (TFT) monitoring completed within the last 4 months. However, we saw that the service had attempted to get the patients into the service without success. They had made telephone calls and sent text messages and were proactively engaging with them to encourage uptake. The service had a policy for people who failed to attend, including reducing prescription dates to encourage attendance.