The OM Surgery

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 were not assured systems in place to promote a learning culture were effective. There was limited evidence of investigation or discussion around incidents and issues; actions were not always recorded, shared, or followed in line with policy. There was no system to monitor progress or improvement from learning. There was limited evidence of appropriate risk assessment in line with guidance. Meetings were ad hoc and minutes were inconsistent. There were potential risks in the care environment. We found systems for managing safe staffing, premises, equipment and environmental risks were not managed effectively. The practice did not ensure that appropriate standards of cleanliness and hygiene were met in line with regulations. Leaders and management had no oversight of the risks above, which is a breach of regulations 12 (safe care and treatment) and 17 (good governance).

This service scored 56 (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 speak to patients during our onsite assessment. Feedback received by CQC before and after the assessment was negative about access to appointments, lack of clinical staff on site, getting through on the practice telephone and overall management concerns. People told us the reception staff appeared too busy to help.

We sought views of practice staff as part of this assessment which were sent to the team via a questionnaire and returned directly to the CQC. We received 9 completed forms, all of which were treated confidentiality. We also spoke to 6 members of the staff team. Leaders acknowledged they did not have a robust process for handling incidents and needed to document incidents/complaints in one place so they can be used as opportunities to learn and make improvements. Not all staff were aware of how to report an incident or significant event. Learning from events was discussed during team meetings, however, not all staff were aware of how to access minutes from the meetings. Staff told us changes at the practice were also communicated via online instant messaging group. Not all staff felt supported by management, who were often not on site to raise concerns with. However, staff acknowledged the practice manager rectified issues quite quickly; for example, a locum GP was employed recently in response to staff experiencing they felt overwhelmed with requests for appointments. Staff employed through the Primary Care Network (PCN), who were assigned to the practice, felt they had to gain support from network management rather that in-house.

We received concerns regarding the management of complaints at the practice. We viewed examples of team meeting minutes which showed they were brief; attendees were not always recorded and there were no standing agenda items. There was evidence of discussions around incidents, but actions were not recorded or followed up to monitor progress or improvement from learning, with no date for next meeting. We saw only one significant event had been recorded in last 6 months where it had been completed adequately. However, there was limited evidence that recommendations for improvements had been implemented, specifically issues around staffing levels and sickness cover which remained outstanding at the practice. The complaints and incidents policies were version controlled, with contact details for the practice manager. However, there was no evidence that complaints forms were available in other languages or other accessible options. The practice provided a sample of patient comments cards during the on-site assessment. There was no evidence of how these had been collated or shared with staff.

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.

We were not assured that the provider had effective arrangements in place to monitor the safety and upkeep of the premises. Although equipment was regularly calibrated and PAT tested, staff highlighted that some of the technology and equipment/office supplies needed updating or replacing. For example, management had been informed the battery for the defibrillator was low and this had not been replaced. A label printer had not been working for three months. Staff told us they felt the general environment needed updating and were concerned about security in some areas, for example there were no blinds in the reception area to reduce visibility through the windows. Staff told us they had asked for a privacy screen at reception; however, this had not been actioned. They also said they often worked alone in the reception area. Staff were unsure who the infection prevention and control lead was within the practice. They told us the practice nurse carried out cleaning audits and monitored temperatures for the vaccine fridges. Leaders acknowledged that risk assessments had not been updated and the building needed modernising and decorating, including making it more accessible with electric doors throughout. Leaders told us the business continuity plan had been recently tested and areas for improvement were identified from the test. Staff had no concerns about the environment in which they worked.

The building had an adequate car park with disabled parking spaces. There was a ramp leading to the front entrance with electronic doors for ease of access. However, the main door to the reception, waiting areas and consultation/treatment rooms were not electronic. The main reception desk was cluttered, and patients could see the receptionists’ computer screens meaning confidentiality could be compromised. It was also easy to overhear staff using the phone. There were no facilities for private conversations. There was a check in screen showing different language options and a hearing loop. A Friends and family feedback box was available. The overall design and layout of the building did not meet the needs of all patients and was in a poor state of repair. Toilets did not have baby changing facilities. There was also a blind spot where it was difficult for the reception team to see patients sat in the corner. We were not assured that the practice had a robust process in place to protect patient data as patient records were not stored securely. Staff offices were cluttered, and patient notes were left unsecured in boxes. Leaders told us records were being moved to a secure room. Equipment which required calibration and PAT testing showed tests were in date, in line with guidance.

We found some risk assessments in place had been completed by the previous provider, and they had not been reviewed or updated by the new provider since they started operating at the practice. For example, the fire risk assessments were out of date. An internal fire risk assessment had been completed by the previous practice manager in 2019 and an externally provided risk assessment was undertaken on 22 September 2022 with a suggested review date of September 2023. There was no evidence of actions from this assessment had been completed. The practice manager informed us they had booked an assessment to be carried out at the end of March 2024. Whilst fire evacuation procedures were visible on the wall, we did not see evidence of fire drills undertaken to ensure staff knew what to do in the event of a fire. Health and safety risk assessments had been completed by the previous provider in September 2023 and legionella risk assessments showed temperature checks had not been recorded since March 2023. We requested for, but were not provided with evidence of fire drills, risk assessments for wheelchair access, lone working and records of staff immunisations. We did not find evidence of robust cleaning audits.

There was no feedback submitted to the local Integrated Care Board (ICB) or posted on NHS.uk website relating to safe and effective staffing. However, feedback received by CQC before and after the assessment indicated concerns regarding lack of clinical staff on site and difficulties in getting through to the practice. There was no relevant patient feedback submitted by the GP practice.

Staff told us that there was not always a clinician onsite during opening hours and they often had to work alone. Staff described a recent incident where a patient was asked to leave the building and they had to seek support for their security from the paramedic after they pressed the panic button. We were not assured there was a clinician on site every morning and afternoon when the surgery was open. The clinical lead provided support via telephone if needed as they worked mainly away from the practice. Most staff felt there was minimal resilience within the team to cover sickness and leave with no formal arrangements in place, resulting in backlogs in scanning and coding of medical records. The lack of cover for sickness absence within the nursing team had resulted in appointments being cancelled. The manager told us there were adequate staffing levels at present and the surgery had increased access to appointments since taking over the practice, with additional clinical support from staff employed through the PCN. There was a new pharmacist starting in April 2024. Staff did not receive supervision in line with the practice policy and the lead GP acknowledged that there was no formal competency check process. Most staff had received an induction prior to the new GP partner taking over the practice and acknowledged that they were given protected time for training and development. Not all staff were aware of how to deal with medical emergencies.

Policies operated by the practice included a clinical training and supervision policy and a general staff training policy. However, these did not contain information on mandatory training for staff. We reviewed staff training records and found considerable gaps in mandatory training and no provision for learning disability training. We were not assured that the practice had robust and safe recruitment practices to make sure that all staff, including agency staff and volunteers, were suitably experienced, competent, and able to carry out their role in accordance with regulations. There were no risk assessments undertaken in relation to the gaps. There was little evidence of checks conducted, or service agreements in place for all agency or PCN staff. Emergency equipment was not was not kept in one place for easy access during an emergency. The emergency kit was not fully stocked, and a number of medicines were out of date. The medical emergencies protocol flow chart made reference to 2 receptionists, with no provision for lone working.

There was no feedback submitted to CQC, the local Integrated Care Board (ICB), or posted on NHS.uk website relating to infection prevention and control. There was no relevant patient feedback submitted by the practice.

Staff we spoke to were aware of IPC practices, for example, how to use spillage kits. However, they acknowledged that the aspects of the building in disrepair would likely fail to meet infection prevention and control standards. Staff told us there was no clear lead in place, however, sharps bins were always emptied, and the clinic room was cleaned. The practice nurse undertook cleaning audits. Leaders acknowledged this was an area which needed review and strengthening.

We found the walls in many rooms were damaged and needed fixing or repairing. There was evidence that some floor and skirtings were in poor condition, and seating in the waiting areas were damaged in several areas and had been temporarily addressed using tape, which had started to peel off. We found that some hand wash facilities were not compliant with cracks in the basin. We found the cleaners’ cupboard was very cluttered and items were stored on the floor, meaning it would be difficult to clean. We saw surfaces within the consultation room were visibly dusty and the couch roll on the treatment couch was dirty. The sharps bin was not signed or dated.

The training matrix we reviewed showed that 9 staff members needed infection prevention and control training. A policy on infection prevention and control was in place but this was not followed effectively. We requested but did not receive details of staff immunisation records to evidence compliance with vaccinations required for specific staff roles, in line with guidance.

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