Hednesford Medical 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

The service had a good learning culture and people could raise concerns. Incidents were investigated. People were protected and kept safe. Staff understood and managed risks. The facilities and equipment met the needs of people, were clean and well-maintained and any risks mitigated and flagged were appropriate to the premises landlord.

There were enough staff with the right skills, qualifications and experience. Leaders made sure staff received training and regular appraisals to maintain high-quality care. Staff managed medicines well and involved people in planning any changes.

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

People felt supported to raise concerns and felt staff treated them with compassion and understanding. Representatives from the Patient Participation Group (PPG) felt the provider took concerns seriously and proactively made improvements to the service. Managers encouraged staff to raise concerns when things went wrong. During staff meetings, the team discussed and learnt from clinical issues. The provider had processes for staff to report incidents, near misses and safety events.

The progress of significant events was discussed, monitored and recorded on a matrix to enable clear managerial oversight. For example, there were 16 events from the period of 1 April 2024 to 31 March 2025. Each event was investigated and processes put in place to mitigate the risk of reoccurrence. After our onsite assessment, the Care Quality Commission (CQC) received information of concern in relation to a paper record event 2 years earlier. Following a discussion with the CQC the provider advised this had been managed at the time and risks of reoccurrence mitigated including updates in their policies and procedures. However, this had not been documented as a significant event or stakeholders contacted. The provider assured the CQC they would complete a retrospective review of the event, contact the Information Commissioners Office and report the concern to the Integrated Care Board and any patients affected would be contacted. The outcome and actions were to be shared to the CQC.

There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Learning from incidents and complaints resulted in changes that improved care for others.

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 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. Nonclinical staff members received care navigation training and staff were supported by a duty GP or clinician who completed clinical triage. The practice ensured there was continuity care for complex or vulnerable patients with named GPs, longer appointments, and carer involvement.

Urgent referrals and referral processes were in place and members of the practice team monitored referral timeframes and contacted patients and services when appropriate to do so for follow up. Child to adult safeguarding transitions were taken account of and discussed at the clinical meetings.

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’s learning disability, autism and safeguarding electronic registers were actively reviewed and updated on an ongoing basis. Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations.

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 action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated. The providers care navigation protocols prioritised vulnerable patients. For example, disabled or older adults, young children, safeguarding concerns, learning disabilities and autism, homelessness, military veterans, and military veterans’ family members.

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 and risks identified had been addressed. The provider received information from their landlord, NHS Property Services, on their maintenance activity. Some areas flagged for action had yet to be completed by the landlord and the provider held records to monitor and highlight any outstanding activity to the landlord. For example, we saw that in March 2025 there had been an emergency lighting failure. The practice manager was aware and had flagged this to NHS property services on several occasions for their action.

The Patient Participation Group (PPG) had fed back to the practice premises garden maintenance. The practice told us that issues raised via the PPG were fed back to NHS Estates for actioning and records kept for audit purposes.

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. Improvements had been made subsequent to the practice inspection in September 2021. We found training 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. Where there were gaps in staff immunity history risk assessments were completed or would take place.

Annual appraisals were completed for all staff, while individuals with enhanced roles received regular competency assessments and clinical supervision. Non-medical prescribers prescribing had oversight and were subject to regular audits and any knowledge gaps supported with additional learning and support.

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 practice had a designated infection, prevention and control 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. The Control of Substances Hazardous to Health (COSHH) records were reviewed and found to be largely complete, with one record requiring follow-up by the practice manager.

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. Improvements had been subsequent to the last inspection in September 2021. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments.

Our clinical searches identified that there had been 208 medication reviews completed in the previous 3-month period. Of the 5 medicine reviews we sampled 1 patient lacked sufficient detail and context. The provider reviewed the record and acted on the feedback provided.

Our clinical searches revealed that 41 of 234 patients prescribed neuropathic pain medicines might not have had a review during the previous 12 months. We sampled 5 of the 41 records. We found that 4 of the 5 were overdue monitoring. As these medicines carry a risk of addiction, they require regular reviews to ensure compliance, prevent and avoid overuse and monitor for side effects. The provider had identified this area for an improvement audit. Following our assessment the provider had contacted these patients for a review.

Our clinical search findings were that 2 patients prescribed a type of diuretic medication that blocks the action of the hormone aldosterone were overdue blood test monitoring. This was actioned by the provider following our feedback.

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 lower than local and national averages. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.