OHP - College Green Medical Practice

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• 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 carried out an announced assessment of 8 quality statements (Learning culture; Safe systems, pathways and transitions; Safeguarding; Involving people to manage risks; Safe environments; Safe and effective staffing; Infection prevention and control and Medicines optimisation) under the safe key question and found: Safety was a priority for everyone and leaders embedded a culture of openness and collaboration. People were always safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination. When people raised concerns about safety and ideas to improve, the primary response was to learn and improve continuously. There was strong awareness of the areas with the greatest safety risks. Solutions to risks were developed collaboratively. Services were planned and organised with people and communities in a way that improved their safety across their care journeys. People were supported to make choices that balanced risks of harm with positive choices about their lives. Leaders ensured there were enough skilled people to deliver safe care that promoted choice, control and individual wellbeing.

This service scored 78 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Through their website, the practice shared minutes of their meetings with the Patient Participation group (PPG) for all patients to view. The practice also shared information on their website about any action they had taken with the PPG to improve services. When people left comments or reviews on the NHS and Healthwatch websites, the practice responded. We saw that all responses were personalised and when feedback was negative, if appropriate, in most cases people had been supported and offered further guidance on what action to take next.

Leaders encouraged staff to raise concerns when things went wrong. Staff had opportunities to raise concerns and learn from incidents and complaints. Staff described an open culture, where they felt supported to raise concerns and shared examples where the practice had contacted patients to explain when something had gone wrong. The practice had received 36 complaints between September 2023 and August 2024. Of these, 34 had either been upheld or partially upheld. The practice contacted all people who complained to provide them with a response.

The provider had processes for staff to report incidents, near misses and safety events. 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. Leaders monitored patient feedback from multiple sources and used this information to continue to develop and improve services. If staff were not able to attend meetings, information relating to complaints and incidents was available to all staff electronically. There were processes in place that allowed leaders to share information from learning events with the provider, and for practice staff to learn from events that had occurred in other OHP (Our Health Partnership) GP practices. There were processes in place to review the number and types of complaints that had been received each year. Leaders compared this to previous years data. Information we viewed showed that the number of complaints received had fallen when compared with the previous year. The practice had a complaints policy. However, the policy did not give sufficient guidance to staff on record keeping processes and was confusing in regards to the method in which people should be responded to.

Patient feedback we reviewed described the service as efficient and organised. When patients needed to be referred, referrals were carried out without delay. Feedback from care homes which the practice provided GP services to, included that there was a smooth transition when their named GP changed. One care home also told us they had received positive comments from residents and their families about the care they had received from the GP. Care home staff told us they received regular ward rounds from practice staff. Their named GP and pharmacist knew their residents well and advice and support was available as needed.

Staff told us that safety and continuity of care was a priority throughout people’s care journey. There was a strong awareness of the risks to people and staff described how they identified and managed these risks. Staff described efficient processes which ensured that test results and communication from external organisations was processed and actioned correctly. Workloads were managed and distributed equally across the staff. Staff communicated with practice staff and external organisations when needed to keep people safe and ensure continuity in care. This included when moving from children to adult services.

Feedback from care homes which the practice provided GP services to was positive about the arrangements in place to communicate with the practice and to ensure that people’s needs were being reviewed and met in a coordinated, safe and timely manner.

Our review of patients’ records and the clinical system indicated that letters, referrals and blood tests results were managed and responded to safely and that leaders had implemented effective processes to manage information relating to patients. We found that the process to manage letters could be improved further to give leaders better insight into areas for improvement or continued assurance that their process was robust and effective. Leaders did not formally audit to see if letters had been coded correctly; however, clinicians provided feedback to non-clinical staff if they identified concerns. We found the practice had effective processes for registering new patients, summarising their records and removing patients that were no longer registered at the practice. The practice had processes in place to monitor that a result had been received for every cervical screen sent off for analysis. Through a recent minor surgery audit, the practice had identified that a result had not always been obtained for every histology sample sent for analysis (2 out of 87). Staff had taken appropriate action following the audit to obtain and review the relevant results. Leaders told us, following the audit they had reviewed and strengthened this process; however, they would be discussing it further at their next clinical meeting.

We could not collect the evidence to score this evidence category. Our observations raised no concerns regarding safeguarding at the service.

There was a strong understanding of safeguarding and how to take appropriate action. Staff liaised with external organisations as necessary to keep patients safe. All staff we spoke with were able to identify and discuss safeguarding concerns and processes. Staff shared examples of when they had gone above and beyond to keep people safeguarded. There was a commitment to taking immediate action to keep people safe from abuse and neglect. This included working with partners in a collaborative way.

The practice had received recognition from the Integrated Care Board for their efforts in keeping people safeguarded.

Safeguarding processes were well embedded at the practice. There were effective systems, processes and practices to make sure people were protected from abuse and neglect. Policies were in place and accessible to staff. The practice had safeguarding leads for children and adults. The practice had systems in place to alert staff to which patients were vulnerable and safeguarding leads had categorised patients according to risk so that they could be monitored accordingly. The practice had processes in place to ensure that staff had completed relevant training. A random sample of staff files we checked showed that all staff had up to date safeguarding training for children and adults at a level suitable for their role.

The practice shared patient feedback with us that showed patients felt they had been provided with sufficient information during their minor surgery procedure. Data from the 2024 National GP patient survey showed that 96% of people that responded to the survey felt they had been involved as much as they wanted to be in decisions about their care and treatment.

Patients were informed about any risks and how to keep themselves safe. Staff would use alternative methods of communication where needed and had access to interpreters. Staff shared examples of where staff had met with patients and/or their families and carers to discuss their care and treatment.

From our record reviews we found that care plans were completed with patients and their carers. Reviews of long term condition records indicated that reviews were thorough and patients were given safety netting advice to deal with risks that may occur. The practice had appropriate processes in place to obtain consent and from our record reviews we saw where appropriate, consent had been sought and recorded. The practice had carried out a minor surgery audit of all minor surgery procedures carried out between March 2023 and July 2024. The audit included feedback from patients and showed that of those patients that provided feedback, all patients felt they had been provided with sufficient information.

Staff told us that clinic rooms on the ground and first floor were mostly used. There was a patient stairway and 2 lifts that went to the other floors. The second floor was accessible by lift only but currently only had 2 clinic rooms in use. If the lifts were not working, then patients were reallocated to clinic rooms on other floors if necessary. The building was owned by an external organisation and the landlord had responsibility for maintenance of the building and grounds. Staff told us they had processes in place to request information or repairs. All staff knew where to find emergency equipment and there was information in each clinical room to remind them. Staff shared examples of when they had responded in an emergency, and reported that staff had acted appropriately. Not all staff we spoke with could recall or show us how to access the Medical emergency policy. This was a newly implemented policy and had not been fully embedded at the time of the assessment.

We observed the premises to be suitable for the services being delivered. They were well maintained and accessible to all patients. The practice provided 4 wheelchairs at the entrance to help patients mobilise around the practice. The car park was shared with the building next door. It had 2 electric vehicle charging points and a secure bike storage area park for patients and staff. Staff had changing facilities and a large staff room. Fire notices and evacuation plans were in place and the building had refuge areas where people using wheelchairs/people with mobility needs could wait with a member of staff until they could be evacuated by the fire service. There were reception desks on the ground and first floor with waiting areas with suitable seating on each floor. There were accessible toilets available on each floor and baby changing facilities on the ground floor. However, there was no designated room for breast feeding mothers to use. Clinic rooms were spacious with appropriate flooring and equipment. Appropriate emergency equipment and medicines were in place and accessible to staff.

The practice had implemented effective processes to help identify, mitigate, monitor and manage risks related to the premises. Information was readily available to staff and leaders shared relevant risk assessments, action plans and other safety information with us either before or during our site visit. The practice had a premises manager that supported leaders in ensuring the premises were safe and that action was taken when risks were identified. Leaders had completed a risk assessment for any emergency medicines they had decided not to keep on site. We found the practice carried out fire drills annually and had plans to carry out medical emergency drills as part of their new policy. Staff had appropriate training in fire safety and basic life support for adults and children and anaphylaxis. The infection prevention and control lead nurse had good communication with both the premises manager and the cleaning staff. There were clear processes for ensuring cleaning was comprehensive, by both clinical and cleaning staff. Records were kept up to date and spot checks undertaken. The minor surgery room was deep cleaned weekly. There were processes in place to check that electrical equipment was safe. The practice had carried out an accessibility audit to ensure all patients could access the premises on an equal basis to others.

Patient feedback we viewed was positive about staff. Patients felt that staff were experienced and the right person to deliver their care. 97% had confidence and trust in the healthcare professional they saw or spoke to during their last general practice appointment

Staff shared examples of where they had worked together with staff from different teams and with staff from external organisations to provide safe care that met patients’ needs. Leaders told us about the processes in place to provide regular clinical supervision and/or support to staff in clinical roles including non-medical prescribers and GPAs (general practice assistants). All staff we spoke with told us they had access to support when they needed it and they felt supported to develop professionally.

Leaders had implemented effective processes to ensure they had the right number of staff and skill mix to support the safe and effective delivery of services. The practice had effective systems in place to monitor that staff were up to date with required training. From staff files that we viewed we saw that staff were up to date with required (mandatory) training. We found effective recruitment processes were in place. Enhanced Disclosure and Barring Service (DBS) checks were in place for staff where needed. DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable. All staff had annual appraisals and either personal development plans or performance reviews. There were processes in place to monitor ongoing professional registration checks. Reception staff had been trained in how to triage patient requests, including how to decide if requests were urgent and on how to signpost patients to other services. GPAs completed competencies before they were allowed to carry out appointments independently. There were opportunities for GPAs to raise concerns about patients and escalate to GPs. Any changes to treatment were carried out by a pharmacist or GP. There was a safety system in place to ensure that all required monitoring had been carried out. However, we found instances where this had not always happened and there was no formal monitoring of GPAs record keeping on an ongoing basis to ensure they had requested support when they needed it or escalated concerns. We also found that the information in the Mandatory Training List and the training log was different which meant some staff were out of date with infection prevention and control training (we did not find any concerns with IPC during our assessment) and the requirements to complete learning disability and autism training was not included in the mandatory training policy.

Patient feedback we reviewed indicated that patients felt the premises were clean and safe.

Staff we spoke with were enthusiastic about ensuring high levels of infection prevention and control (IPC) within the practice. Staff told us they had a good relationship with the premises manager and cleaning staff and this helped to ensure high standards of cleanliness.

We observed the practice to be visibly clean; surfaces were uncluttered and pedal operated clinical waste bins were in use. We did not identify any IPC concerns during our visit. Vaccine fridges were suitable and not overfilled; the temperature of these was monitored and all stock we checked was in date. All clinical rooms had information for staff on: bare below the elbows, sharps segregation, sharps injuries and handwashing procedure. All sinks were elbow / wrist operated and soap / gel / towels were available. Personal protective equipment (PPE) was available in all the clinic rooms we inspected. Spill kits were available on each floor. We saw that clinical waste awaiting collection was stored securely.

The practice had a lead for IPC. This staff member had received appropriate training to carry out their role and had implemented a robust and effective IPC monitoring and audit system. There was training on IPC and sepsis for all staff at the appropriate level. All staff were trained in sepsis and most staff had completed IPC training at a level appropriate to their role. We found the training policy had not been updated to reflect the updates in the frequency of training, which meant some staff were non-compliant. We found the IPC policy lacked practice-specific detail. Staff told us this policy was being revised at the time of the assessment. There were processes in place for identifying, recording, actioning and disseminating learning from significant and learning events relating to cold chain events The practice had a nominated room for isolation if needed and had an effective policy covering one way systems through the building for infected and non-infected patients in the event of a pandemic. The practice had effective processes to manage sharps and waste management. There were cleaning schedules and cleaning materials in each clinic room and staff had a reminder appointment slot at the end of the day for cleaning. The provider had systems in place to collect and record information relating to staff immunisations status. There were clear processes for ensuring cleaning was effective. Records to evidence that cleaning had taken place were kept up to date. Cleaning by staff and cleaners was audited and spot checked. The minor surgery room was deep cleaned weekly.

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 told us people were involved with assessments and reviews about the level of support they needed to manage their medicines safely and to make sure their preferences were included. For example, when starting patients on new medicines staff explained the benefits and tried to support with the best option. Staff would also arrange an appropriate follow up to review that the medicine remained the best option for them. Staff felt confident managing the storage, administration and recording of medicines. Staff followed protocols to ensure they prescribed all medicines safely, and ensured people received recommended medicines reviews and monitoring. Staff and leaders described the processes they had implemented to ensure that medicines and treatments were safe and met people’s needs. Staff were proactive in contacting patients if they identified any errors or if further information was needed. If there were concerns about specific patients, for example if a patient was not complying with monitoring requests, staff discussed their concerns during clinical meetings, where the risks could be discussed and an action plan formed. Staff in different teams worked together to optimise patient treatment and care.

Staff managed medicines safely and regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments. Medicines were stored appropriately with access given to appropriate staff. We checked a sample of medicines at random and found they were in date. Blank prescription stationery were kept securely. Emergency medicines were accessible to staff in the event of an emergency.

The practice had processes in place to review and monitor that staff had the correct authorisation to administer vaccinations and medicines. For example, patient group directions (PGDs) and patient specific directions (PSDs) we viewed were in date and fully completed. The practice had systems in place to receive, share and act on safety alerts. There were effective processes in place to respond to blood test results and correspondence from external organisations when changes to medicines were required. There was a process for the safe handling of requests for repeat medicines and evidence of effective medicines reviews for patients on repeat medicines. Leaders carried out regular medicine prescribing audits to ensure that care and treatment was in line with national guidelines and that they had acted appropriately following safety alerts. Our record reviews and review of the clinical system indicated that care records were managed in a way to protect patients. For example, in records we viewed information on history, examination, management plans, safety netting and follow up were adequately documented within the patient record. We also found that mostly patients’ treatment was monitored in line with guidelines. Where information was missing from patient records or the practice could not evidence that monitoring had occurred in line with guidelines, we discussed this with leaders who were able to provide assurances around their safety processes and that patients were prescribed medicines safely. There were effective systems in place to safeguard blank prescription stationery and monitor its use.

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. There was a programme of regular clinical auditing of prescribing that focused on improving care and treatment.