Bewdley 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

During the assessment we reviewed policies, procedures, spoke with staff and undertook observations while on site. We completed remote clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements). We found the practice had systems and policies in place to keep people safe. Learning was shared effectively and used to make improvements.

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 evidence we reviewed did not show any concerns about people’s experience regarding learning culture at this practice.

Feedback from staff and leaders demonstrated that the practice had a proactive and positive culture of safety based on openness and honesty. Staff told us safety events were investigated and reported thoroughly, and lessons were learnt to identify and embed good practices. Staff and leaders were able to share examples of incidents which had been investigated and actions identified. Learning and agreed actions from incidents were shared with staff.

The practice had a significant events policy in place. The practice followed this policy and discussed events and incidents during team meetings. The practice had a Duty of Candour policy and involved people when managing significant events and errors. The service acted on and learned from external safety events as well as patient and medicine safety alerts. The service had an effective mechanism in place to send alerts to all members of the team.

The evidence we reviewed did not show any concerns about people’s experience regarding safe systems, pathways and transitions at this practice.

Staff and leaders told us they were aware of the safeguarding systems, processes and practices. Staff told us there was a documented system for referrals and there was a system to monitor delays in referrals. Staff told us they knew how to communicate results to patients and this was reflected in the policy for management of test results.

The provider shared information where appropriate with other agencies. We received feedback from the Integrated Care Board (ICB) who confirmed they had no concerns with the systems, pathways and transitions of the practice.

The practice had a documented approach to the management of test results, and this was managed in a timely manner. The practice had a duty doctor who reviewed the results for staff not working. Our searches showed no concerns for the management of test results.

Staff were trained to recognise the signs of abuse and were supported to take action by the safeguarding lead. Staff told us they knew how to recognise and raise a safeguarding concern.

The provider shared information where appropriate with other agencies to ensure people were safe from harm. This included the out of hours service and mental health teams. We received no concerns from the ICB about safeguarding for this practice.

There were effective systems and processes in place to make sure people were protected from abuse and neglect. All staff had received safeguarding training to a level appropriate to their roles within the practice. Staff worked collaboratively to identify vulnerable patients and patients who may be at risk of harm. The practice held regular meetings every 6-8 weeks to discuss safeguarding concerns.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

Staff told us they had routine fire drills and knew how to raise the alarm to alert patients and other staff in an emergency. Staff were clear on their roles and responsibilities.

Facilities and equipment in the premises were well-maintained and were suitable for the intended purpose.

The service had effective arrangements to monitor the safety and upkeep of the premises. The service conducted safety risk assessments such as fire, Control of Substances Hazardous to Health (COSHH) and Legionella (a term for a particular bacterium which can contaminate water systems in buildings). The service undertook annual portable appliance testing (PAT Testing) and all medical equipment was re-calibrated annually.

The evidence we reviewed did not show any concerns about people’s experience regarding safe and effective staffing at this practice.

Staff received effective support, supervision, and development to deliver safe care. Staff told us the training was appropriate and relevant to their role. Staffing levels were sufficient to provide care and treatment. Staff told us staffing levels were adequate to cover absences and busy periods.

Staff were recruited safely and in accordance with regulations. All necessary pre-employment checks were being completed. This included asking for references and completing checks with the Disclosure and Barring Service. These checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

The evidence we reviewed did not show any concerns about people’s experience regarding infection prevention and control (IPC) at this practice.

Staff had completed appropriate IPC training relevant to their role. Staff told us they knew their roles and responsibilities around IPC. For example, one member of staff told us where to find the appropriate equipment to deal with spillages of body fluids and how they would report this.

We observed the premises to be visibly clean. All staff we observed adhered to current IPC guidance. Staff had access to appropriate personal protective equipment (PPE) and hand washing facilities in clinical rooms. Staff maintained a hygienic environment by cleaning equipment between use, disinfecting surfaces, and routinely cleaning clinical areas.

There was an effective approach to assessing and managing the risk of infection, which was in line with current relevant national guidance. The practice had an IPC lead and the practice completed yearly audits on hand hygiene and acted on any issues identified. The practice had arrangements in place to manage healthcare waste and staff were aware of the action to take in event of sharps or contamination injury.

The evidence we reviewed did not show any concerns about people’s experience regarding medicines optimisation at this practice.

Staff and leaders told us they had systems and processes in place to support the safe prescribing of medicines.

During our checks we found the practice held appropriate emergency equipment and medicines and were checked on a regular basis. Emergency medicines were stored safely and securely with access restricted to authorised staff.

The practice had systems in place for the appropriate and safe use of medicines, including medicines optimisation. 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, and their use was monitored in line with national guidance. The practice could demonstrate the prescribing competence of staff and there was regular review of their prescribing practice supported by clinical supervision.

During our clinical searches, we observed processes in place for monitoring patients’ health. This was in relation to the use of medicines including medicines which require monitoring with appropriate clinical review prior to prescribing. We found no concerns with our clinical searches.