Albany 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

At the last assessment, the practice was rated as good for providing safe services. At this assessment, the safety of services provided was assessed due to the aged overall rating of requires improvement. At this comprehensive assessment, we found the practice’s approach to managing risks was very proactive. We were assured that the process for reporting, investigating and learning from significant events, safeguarding concerns and complaints were robust and that staff were able to access information regarding them as staff meeting minutes were regularly documented. We found robust documentation of staff recruitment, induction, staff training and immunisation records. We found an audit of infection prevention and control (IPC) with actions assigned to relevant staff within a specific time-frame. The staff knew who the IPC lead was as well as the safeguarding leads. There was a fire risk assessment with the risks associated with fire safety and fixed electrical installation mitigated against, compared to the last inspection findings. Our assessment found that the IPC policy was last reviewed in April 2023 which made it overdue for a review, and the practice was made aware and responded that the policy will be reviewed. Our clinical searches identified the clinical IT system used by the practice was not efficiently configured which meant clinical staff were not able to identify patients with overdue medication reviews in a timely manner and the management of medicines to treat insomnia, medicines with potential for addiction or misuse, patients with long term conditions and those with missed diagnosis.

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.

Patients knew how to complain and who to complain to. There was information on the practice website and visible complaints procedure displayed in the practice for those who were digitally excluded. Members of the PPG felt the practice had improved.

The registered manager handled all complaints, and the practice had received 21 complaints in the last 12 months. All complaints were handled according to practice’s complaints policy. Staff said team meetings were regularly conducted with the minutes recorded and shared. There was a log of complaints, significant events actions taken, and lessons learned. There was a clear process for reporting, investigating and learning from significant events and complaints.

The practice manager and the GP partners showed us complaints and incident policies including significant event policies. There was a clear demonstration of how the practice handled events and complaints and the lessons learned with the action plan drawn up to prevent recurrence.

Patients did not have any complaints about the systems except for access and appointments.

Staff understood their responsibilities to process routine referrals. Staff understood their responsibilities to manage urgent cancer referrals and follow these up to ensure patients had attended their appointments within the two-week wait period. Clinicians could not demonstrate complete oversight of the monitoring of people with long-term conditions including people’s medicine reviews. Following the assessment and clinical searches, leaders provided a significant event analysis audit and action plan to mitigate the risks and make required improvement to ensure effective oversight by configuring the IT clinical system using provided search filters.

The feedback from the commissioners did not raise any concerns. We noted from multi-disciplinary meeting minutes evidence of discussion with other health and care professionals who work with the service to manage vulnerable adults.

During the assessment we found that some clinical findings were not recorded in the patient record and there was no evidence of follow-up of the patient. Following the assessment, leaders provided a significant event analysis audit and action plan to mitigate the risks and make required improvements. We saw evidence of clinical meetings and staff meetings minutes that demonstrated that the practice worked with other healthcare professionals such as palliative care team, district nurses, social workers to ensure a positive patient outcome.

People did not raise any concerns about safeguarding during the assessment.

Staff could explain how safeguarding concerns were recognised and how they would be reported. Staff knew who the safeguarding leads were for adult and children.

We did not receive any specific concerns from commissioners or other partners about safeguarding.

At the assessment, we found that staff had received Disclosure and Barring Service (DBS) checks before commencing work at the practice. Safeguarding adults policy as well as that of children were up to date. Staff training relevant to safeguarding adults and children were undertaken and up to date. Patients with safeguarding concerns had it recorded in the patient record.

Patients felt they were less involved in their care and treatment than they would like to be. Results from the national GP Patient Survey showed that the practice was below the national and local averages. The practice had drawn up an action plan to rectify this by extending consultation times and launching targeted training programmes to improve communication skills and patient engagement.

Staff understood the role of involving people in making decisions about their care and treatment. Risks were identified and discussed with people and documented in the patient records such as do not attempt cardiovascular resuscitation (DNACPR) decisions.

There were adequate systems to monitor and manage risks to people’s safety.

The staff and leaders had oversight as clearly defined by their roles and ensured that all responsibilities were carried out safely. However, there had been challenges with the cleaning schedules as this task was managed by NHS Property Services who owned the building that housed Albany Practice

The building housing the practice was shared by 2 other GP practices. A defibrillator was located at the reception and shared with other practices and checked monthly. Medical oxygen and emergency medicines were stored in the practice nurse room and were within date except for one emergency medicine which was expired. The expired medicine was removed when pointed out by the inspection team during the site visit.

There was a policy for health and safety; risk assessments were conducted with all required action plans drawn up and assigned to relevant staff for follow-up. Fire safety training was completed by staff. The practice had risk assessments in place to ensure the safety of patients and staff. They included risk assessments for fire safety, general health and safety, legionella bacteria including action logs. Medical equipment calibration and Portable Appliance Testing (PAT) certificates were in place and a business continuity plan, all of which were up-to date. The business continuity plan detailed what actions were to be taken in the event of any incident that would hamper the running of the services.

Patients felt that the staff were friendly and helpful. However, there was need for improvements in the interactions between clinicians and patients. Patients who spoke to us felt that the appointments were rushed and getting to see the clinicians in a timely manner would be beneficial.

Staff told us that the staffing level was sufficient and staff holidays, sickness / absence were covered adequately. The practice was in the process of finalising discussions to have an additional GP partner.

The staff records reviewed by the inspection team were all up to date and included a formal induction process for new staff members and staff vaccination records. All staff trainings were within date with alerts / reminders sent to staff about soon to expire training. All staff were Disclosure and Barring Service (DBS) checked with risk assessments completed every year. Staff had completed chaperone training. All relevant policies were reviewed regularly and within date.

Patients did not have any concerns about infection prevention and control (IPC).

Staff were aware who the IPC lead was for the practice and IPC audits were completed six monthly.

We observed a sharps bin and a clinical waste in a clinical room. We observed the practice to be generally clean. Soap dispensers and paper towels were available.

We found that details of the immunisation status of clinical and non-clinical staff were kept. The practice had an infection prevention and control (IPC) policy that was last reviewed in April 2023 thus making the policy overdue for a review. However, there were six-monthly IPC audits completed with the latest completed 6 September 2024. The IPC audit report completed by a professional company highlighted several areas of IPC that the practice was not compliant with. In response, the practice had developed an action plan to correct the areas of non-compliance. These actions would be completed in conjunction with the NHS Property Services who own the building with various responsibilities assigned to members of staff at Albany Practice with specified timelines for completion. Training would be delivered by the IPC company to update staff training.

Patients did not share any concerns about their medicines.

At this assessment, we found inconsistencies with the practice's compliance with medicine alerts discovered during the clinical searches, however, the practice had completed a significant event analysis (SEA) of medicines prescribed to patients of childbearing age that could potentially cause harm during pregnancy. The analysis highlighted that clear and consistent documentation of discussions surrounding medicine risks, particularly for patients of childbearing age were required. This was to be achieved through improvements to procedures, raising awareness among staff, and implementing practical changes such as electronic medical records (EMR) prompts and regular audits.

Emergency medicines and vaccines were stored in the practice nurse room with required temperature checks and audits completed. There were no controlled drugs stored on site. The patient group directions (PGDs) were up to date and the patient specific direction (PSD) were recorded in individual patient records.

Our clinical searches identified some patients’ medication reviews were overdue as the alerts on the IT clinical system were disabled, therefore staff did not know about it until our remote clinical searches had been completed. It was discovered that the IT clinical system currently used by the practice was not configured for it to be fully optimised by staff. In response to this, the practice completed a significant event analysis which included an action plan to mitigate the risks by working closely with the Integrated Care Board (ICB) and Primary Care Network (PCN) and updating the training for all staff at the practice. The practice had arrangements to respond to medical emergencies. There were emergency medicines stored in the nurses room. However, we found an expired medicine in the emergency medicine box which was removed when pointed out by the inspection team during the site visit. Staff were trained on basic life support, infection control, sepsis awareness and recognising signs and symptoms of life-threatening condition that require immediate attention.

The prescribing data of Albany Practice reviewed as part of our assessment included antibiotics, and psychotropics which showed that the practice was performing in line with national averages to reduce the risk of antimicrobial resistance and the misuse of addictive medicines.