Billinge 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

We assessed two quality statements in the safe key question and found areas of good practice. The scores for these areas have been combined with scores based on the rating from the inspection in September 2023 which was inadequate. Though the assessment of these areas indicated good practice since the inspection in September 2023, our rating for the key question remains inadequate. During the assessment we reviewed records, spoke with staff, and undertook observations of the premises. We found the following: • Action had been taken to assess risks relating to the premises and take appropriate action. • Checks of the safety of equipment had been undertaken. • Staff had the required training for their roles. • There were safe recruitment procedures.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

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 and leaders told us they had reviewed the systems in place to ensure that risks to patients and staff from the premises were identified and addressed. Following the inspection in September 2023 leaders had developed an action plan to demonstrate how they would address the improvements needed to the safety of the premises. At this assessment we reviewed the action plan alongside documentary evidence and observations and found action had been taken to assess the safety of the premises. We found that action had been taken or was planned to address any shortfalls identified. There was a system in place to ensure safety checks were re-visited at the recommended frequencies.

We looked at a sample of areas at the premises. Hazardous substances identified at the inspection in September 2023 had been removed. Leaders confirmed that this was addressed shortly after the last inspection. We saw that changes had been made to the premises as a result of the safety assessments carried out. For example, fire doors had been replaced and new fire safety signs had been displayed. A pull cord had also been made available in the toilet for people with a physical disability. During our observation of the premises, we found that the cupboard for storing cleaning materials was unlocked. Cleaning was in progress at the time, and this was addressed immediately by leaders.

Following the inspection in September 2023 leaders had taken action to ensure that assessments of the safety of the premises were in place, comprehensive and up to date. We saw risk assessments had been completed in relation to fire safety, legionella, health and safety and disability access. An action plan had been documented for these risk assessments indicating action taken and a timescale for completing unresolved actions. At the last inspection there was no documented evidence that the emergency lighting and electrical wiring were safe. At this assessment this had been addressed.

We met with representatives of the Patient Participation Group (PPG). We also obtained the views of patients by reviewing Healthwatch feedback, information collected from patients by the PPG, information collected by leaders and feedback from patients on the NHS.uk website (formerly NHS Choices). Feedback showed that patients considered improvements had been made at the practice in terms of access by phone, access to appointments and additional services.

Staff and leaders told us they had reviewed the systems in place to ensure that staff had the training they required for their roles and to ensure safe recruitment practices were followed. Following the inspection in September 2023 the leaders had developed an action plan to demonstrate how they would address the improvements needed to training and recruitment. They provided an audit to demonstrate that recruitment records had been reviewed to identify shortfalls. They also provided an overview of staff training records to demonstrate that staff training was up to date.

We reviewed the recruitment records of 4 staff employed since the inspection in September 2023 and found that these contained the required information. We also reviewed staff training records and looked at a sample of training certificates. We found that staff had received the required training for their roles. There was a system in place for leaders to oversee staff training so that they could ensure staff completed updates. There was a system to ensure staff had the time to complete the training required for their roles.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.