The Firs 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

The leaders had implemented new systems, practices, and processes to keep people safe. The practice has systems in place to manage risks to patient safety. The practice had an effective system in place to ensure the appropriate and safe use of medicines. The practice learned from significant events and safety alerts and made improvements. The practice had a system in place to help ensure there was sufficient skilled and competent staff. The premises were clean and tidy and maintained by the leaders. Most of people’s feedback in the national GP, friends and family, and the practices own survey reflected positively on the practice.

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 national GP patient survey carried out from January to March 2024 had 90 responses. This found 85% of patients stated the healthcare professional was good at listening to them, and 95% of patients stated they were involved as much as they wanted to be in decisions about their care and treatment. In addition, 95% of patients had confidence and trust in the health care professional they saw or spoke to. CQC did not speak to patients on the days of the assessment. The practice submitted their own unverified survey carried out in July 2024 where they received 278 responses. This found 84% of patients stated the healthcare professionals were fairly to very good at treating them with care and concern, and 87% of patients stated they were fairly to very good at listening to them.

Leaders and staff told us they knew how to identify and report concerns, safety incidents and near misses both internally and externally. They were able to discuss evidence of some learning and dissemination of information. Leaders described a system for recording and acting on patient safety alerts. Staff told us that complaints were responded to promptly, discussed at governance meetings and lessons were learnt. Staff we spoke with felt able to raise concerns and said they were encouraged to do so. The practice had carried out an independent staff survey in June 2024, 15 out of 29 staff responded, they agreed that their manager encouraged them to raise issues without fear of getting into trouble. The staff we spoke with and those who completed a questionnaire also said they felt comfortable raising concerns.

The practice had a system in place to manage safety alerts, which was supported by a Central Alerting System Policy last reviewed in 2024. As part of our assessment, several sets of clinical record searches were undertaken by a CQC GP specialist adviser. These searches were visible to the practice. We reviewed 5 patient records who may have been affected by a Medicines and Healthcare products Regulatory Agency alert and found although they had been incorrectly coded on the patient computer record system all had been informed of the side effects of the medicines. A review of the significant events and incidents process found that the practice had a system in place to report, investigate and learn from significant events and complaints. Significant events were standard agenda items at clinical and practice meetings, and where learning was discussed. The practice had a significant event leads for clinical and administration events. We reviewed 2 complaints and two significant events which demonstrated the systems at the time of the assessment were effective. There was a system to record and investigate complaints. The complaints we reviewed showed they were recorded, investigated and people were informed of outcomes. People received an apology, and actions were taken to improve processes. Lessons learnt were discussed with staff directly involved with complaints and with clinical members of the team. The provider encouraged audit as an outcome of learning from an event. The practice had a duty of candour policy in place which was last reviewed in August 2023, and we saw that it was considered as part of the complaints and significant events processes.

The national GP patient survey carried out from January to March 2024 had 90 responses. This found 80% of patients stated the healthcare professional was good at treating the patient with care and concern, and 95% of patients stated they were involved as much as they wanted to be in decisions about their care and treatment. In addition, 91% stated their needs were met. When asked about overall experience of contacting the practice, 76% stated this was fairly or very good. CQC did not speak to patients on the days of the assessment. The practice submitted their own unverified survey carried out in July 2023 where they had received 278 responses. This found 84% of patients found the healthcare professionals were fairly to very good at treating them with care and concern, and 87% of patients stated they were fairly to very good at listening to them. CQC did not speak to patients on the day of the on-site inspection.

Leaders and staff told us there was a designated lead for referrals who monitored the system to ensure referrals to specialist services were documented, contained the correct information, there were no delays and included safety netting to ensure all patients were followed up. In addition, routine referrals were monitored either to ensure patients continued to require the specialist support or check if their condition had intensified. The leaders explained they had oversight of the workflow tasks to ensure they were all responded to promptly.

The leaders explained they had a multidisciplinary team meeting monthly to discuss and improve outcomes for people with complex needs and a three-monthly meeting with the health visitors to discuss child and adult safeguarding. The local integrated care board told us they did not have any concerns about the practice.

The practice had an administration and clinical lead for patient referrals, this enabled staff to monitor and follow up urgent referrals and identify any delays. The leads met weekly to review the referrals. This was supported by a referrals policy last reviewed in April 2024. The provider had a system in place to ensure all patient results and correspondence was followed up promptly. The staff demonstrated there was a system in place to summarise patient records.

We could not collect the evidence to score this evidence category.

The practice had a safeguarding GP and administration lead who were allocated time to review patients where there were safeguarding concerns. Internally the staff met monthly to review patients of concern. The practice also monitored children who were not brought to appointments. Non-clinical staff told us they were aware of who to report any safeguarding concern to.

The children’s safeguarding leads met every three months with the health visiting team and reviewed any children at risk. In addition, vulnerable adults were included in the monthly meeting with the integrated care board.

The practice had systems, practices, and processes to keep, people safe and safeguarded from abuse. A review of patient records found the practice had a system to highlight vulnerable adults and children to staff. The leaders submitted safeguarding children and vulnerable adults’ policies last reviewed in 2024, which provided information for staff to follow to enable the safe response to a safeguarding concern. All staff had completed the appropriate safeguarding prevent radicalisation training. The leaders explained they had a system in place to review the safeguarding registers.

The national GP patient survey carried out from January to March 2024 had 90 responses. This found 95% of patients had confidence and trust in the health care professional they saw or spoke to. Seventy six percent of patients stated the overall experience of contacting the practice was fairly or very good and 90% of patients knew what the next step would be after contacting this GP practice. The practice submitted their own unverified survey carried out in July 2023 which had received 278 responses. This found 73% of patient found their experience of the GP practice overall as fairly to very good. CQC did not speak to patients on the days of the assessment. We were provided with patient feedback from local Healthwatch they had gathered from social media and the provider website from July 2023 to April 2024, found 37 positive and 10 negative comments. The positive comments covered the booking system, the quality of the practice, and reception staff. The negative comments were regarding practice administration and medicines.

Staff told us there was an effective approach to managing staff absences and busy periods, this was reviewed weekly and at the Partner meetings. Receptionists told us the actions they would take if they encountered a deteriorating or acutely unwell patient. Leaders told us there were enough staff to provide appointments and prevent staff from working excessively. They explained staff had induction tailored to staff roles and a probationary period. The leaders told us that the practice offered 80 appointments per 1,000 patients, which were within the NHS contract limits.

We observed the practice was equipped to respond to medical emergencies, including suspected sepsis and staff were suitably trained in emergency procedures. Staff had complete sepsis, basic life and anaphylaxis training where appropriate. The practice operated a digital/telephone hub, where patients could contact the practice using a digital platform or by phone. All contacts were reviewed by a GP. and responded to within 3 hours. Reception staff had the support of a GP to enable them to respond to patient needs. All staff had completed basic life support and anaphylaxis training.

The provider told us that facilities and equipment were safe, and that equipment was maintained according to manufacturers’ instructions. There were systems for safely managing healthcare waste. Staff explained any maintenance concerns were promptly responded to by the leaders and improvements had been made. The leaders explained that fire wardens were available.

We visited the practice, and observed it was well maintained and there were systems to ensure equipment was safe to use. We saw risk assessments were in place for fire safety, and legionella and actions had been taken.

The practice had completed fire risk, and legionella risk assessments, fire drills and emergency lighting checks, health and safety and most actions had been marked as completed. The practice provided evidence of annual portable appliance testing, and calibration of equipment for all sites. All staff had completed their fire safety training and the principles of health and safety training.

The national GP patient survey carried out from January to March 2024 had 90 responses. This found 95% of patients had confidence and trust in the health care professional they saw or spoke and 85% stated the health care professional was good at treating the patient with care and concern. In addition, 91% stated that their needs were met. 76% found the receptionists helpful which was slightly below the 83% of the national average. The practice submitted their own unverified survey in July 2023 which had received 278 responses. This found 84% of patients found the healthcare professionals were fairly to very good at treating them with care and concern, and 87% of patients stated they were fairly to very good at listening to them. In addition, this found 73% of patient found their experience of the GP practice overall as fairly to very good. We were provided with patient feedback from local Healthwatch they had gathered from social media and the provider website from July 2023 to April 2024, found 37 positive and 10 negative comments. The positive comments covered the booking system, the quality of the practice, and reception staff. CQC did not speak to patients on the days of the assessment.

The leaders told us they had a system in place to ensure safe recruitment of staff. They explained staff had a programme of learning and development in place, and the provided protected learning time and appraisals included their learning and development needs. They kept a training matrix for mandatory training which the practice manager reviewed regularly and was reviewed at partner meetings. At the time of the inspection, the leaders told us they had 1 independent prescriber, who carried out medicine and long-term health condition reviews. In addition, four practices nurses and a nurse associate. The leaders explained there was a system in place to carry three monthly reviews of clinical staff’s consultation records and annual appraisals. The leaders told us that staff always worked within their job description and competency. The leaders told us that the practice offered 80 appointments per 1,000 patients each week which was within the NHS contract limits. The practice had carried out an independent staff survey in June 2024, 15 out of 29 staff responded, 73% stated they received regular feedback on their performance, 93% stated they received training and opportunities to develop their roles, and 67% stated they had sufficient staff in their team to cope with the workload.

The practice had a recruitment policy, last reviewed in February 2024; this included the necessary recruitment checks. Staff vaccination was maintained in line with national guidelines. We reviewed 5 staff files and found all the necessary checks had been completed. The leaders submitted information to demonstrate staff had completed the necessary mandatory training, such as safeguarding adults and children, infection prevention and control, fire safety and basic life support. We saw there was a system in place to carryout clinical staff patient consultation reviews three monthly.

We could not collect the evidence to score this evidence category.

The leaders explained the practice nurse was the lead for infection prevention and control, and they carried out regular infection prevention and controls checks of the premises. In addition, staff carried out daily checks of the rooms they worked in.

We visited the practice and found appropriate standards of cleanliness and hygiene were being met. We saw that clinical bins were stored securely; however, we observed the clinical waste was not labelled prior to collection.

Staff had completed an infection prevention and control audit in June 2024 and had a system in place to ensure that the rooms were checked. The practice had acted on any issues identified in infection prevention and control audits. The practice had completed legionella risk assessments for both sites and had carried out remedial action. All but one staff member had completed infection prevention and control training.

We could not collect the evidence to score this evidence category.

The leaders explained there was a process for monitoring patients’ health in relation to the use of medicines including high-risk medicines (for example, warfarin, methotrexate and lithium) with appropriate monitoring and clinical review prior to prescribing. Staff told us they had a system in place to ensure the safe prescribing of patient’s repeat medicines. Staff explained the systems they used to monitor vaccines, emergency equipment and medicines. At the time of the assessment, leaders said the practice had 1 independent prescriber.

We saw staff ensured medicines were stored safely and securely with access restricted to authorised staff. Staff had the appropriate authorisations to administer medicines (including Patient Group Directions or Patient Specific Directions). There was a process for the safe handling of requests for repeat medicines and evidence of effective medicines reviews for patients on repeat medicines. Blank prescriptions were kept securely. The practice held appropriate emergency medicines, risk assessments were in place to determine the range of medicines held, and a system was in place to monitor stock levels and expiry dates. There was medical oxygen and a defibrillator and systems to ensure these were regularly checked and fit for use, which staff had access to. Vaccines were appropriately stored, and transported in line with UKHSA guidance to ensure they remained safe and effective.

The practice had a system in place to monitor the storage of medicine, this was supported by a policy which was last reviewed in January 2025. The practice had put systems in place to monitor the safe administration of patients’ medicines, the prescribing of repeat medicines and the monitoring of emergency medicines. The practice had purchased computer management software to enable them to monitor the safe prescribing of medicines. The practice had systems in place to monitor the temperature of vaccine fridges. The practice had purchased computer monitoring software to monitor safe prescribing of medicines.

As part of our inspection a number of set clinical record searches were undertaken by a CQC GP specialist advisor. These searches were visible to the practice. We found that monitoring was appropriate overall. The clinical searches found patients receiving the high-risk medicine methotrexate were put on repeat prescriptions, recalled for tests as required by guidance, and the GP was responsible for checking the necessary tests were conducted prior to prescribing. We identified 21 out of 722 patients receiving medication for kidney disease who may have not had the correct monitoring. We sampled 5 patients and found they been offered reviews and where they the patient had not responded this was documented. A search for patients diagnosed with asthma where asthma inhalers may have been over prescribed, identified 614 patients with asthma and 4 where it may have been over prescribed. We reviewed the 4 patients and found no concerns. We found the practice had completed 655 annual medicine reviews in the last three months. We reviewed a sample of 5 and found 3 where the reviewer had not reviewed all the medicines prescribed.