Great Barr 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

At this assessment we found health and safety risk assessments and an infection control audit had been completed to identify potential risks to patients or staff, however the actions identified had not been acted on and we were unable to gain assurances that the leadership team were aware of the outstanding actions.

The practice had taken some action to improve processes or safeguarding registers with staff having completed training relevant to their role and safeguarding registers being maintained, but we found medicines optimisation, the management of long term conditions, the actioning of safety alerts, safe and effective staffing, learning from incidents and significant events had not been embedded to ensure people’s safety was integral to the care and treatment they received.

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.

Information reviewed demonstrated that people had opportunities to provide feedback and they knew how to make a complaint. Feedback and information were available in the practice and on their website. People told us they had enough time during their consultation, however feedback from the GP National Patient Survey showed below local and national average score from people who stated that during their last appointment, the healthcare professional was very good or fairly good at listening to them.

Staff and leaders understood their duty to raise concerns and report incidents and near misses. However, we were unable to gain assurances that learning from incidents and complaints was shared with the practice team to identify learning and mitigate future risks. We reviewed a random sample of minutes of meetings and found some incidents had been discussed, however incidents that the CQC had been made aware of had not been documented or learning had been shared.

The practice had a significant events policy and a reporting form which was accessible to all staff members. We found that the practice had not followed their significant events policy and discussed events and incidents during team meetings and shared learning with staff. The practice had a system in place to record and investigate complaints. The practice had a complaints procedure in place. When we reviewed the clinical system remotely we found a number of outstanding tasks to the leadership team concerning people who had requested a follow up to their complaint which had not been acted on.

Information we reviewed during our inspection demonstrated that not all patients' received appropriate care. We found assessments of people's health needs were carried out by staff who had not completed the appropriate training or had the relevant qualifications to do clinical reviews.

Leaders told us that clinicians made appropriate and timely referrals in line with protocols and up to date evidence-based guidance. On reviewing the clinical system we found the systems in place were inadequate with test results not being acted on and people were not followed up appropriately. For example: We found 4 people with a potential missed diagnosis of diabetes. Clinical coding had not been added to the records to identify them as having risk of diabetes and people had not been referred for the appropriate screening.

The provider told us they were part of the primary care network and they attended regular meetings. However we were unable to gain assurances that regular meetings were held with other agencies across the locality to share and discuss information relating to care and treatment. We were provided with minutes of a safeguarding meeting held in August 2024, but there was no details of who had attended and what was discussed.

We found there were limited safe systems of care, in which safety was managed and monitored. For example, we were unable to gain assurances that there was a system for processing information relating to new people including the summarising of new records. There were systems in place for referrals to appropriate services, however the actioning of test results required strengthening to ensure care and treatment was managed appropriately.

We identified staff working in roles where they would carry out assessments of people's health needs, but no evidence to demonstrate they had completed the relevant training for their role. On reviewing a random sample of clinical records we found inadequate examination and history recorded, wrong dose of medicines prescribed and no evidence of clinical oversight in place.

The practice had implemented processes to ensure safeguarding registers were maintained. We found staff were aware of who the safeguarding lead was at the practice and how to report safeguarding concerns. Since the last assessment the practice had strengthened their safeguarding processes to ensure they held up to date information on people with a safeguarding concern.

The practice had a safeguarding lead for adults and children and policies in place to support staff in the event of a safeguarding concern. Staff we spoke knew of the policies and procedures available to support them and what to do if they had any concerns. The practice held a safeguarding register, and clinical system alerts were used to identify people who were at risk of harm or abuse. Staff were aware that these flags could indicate a potential risk.

The practice had reviewed their policies for safeguarding and had strengthened this further. For example, following the last assessment in May 2024, the safeguarding registers had been reviewed and updated. Clinical coding has been used appropriately to identify safeguarding concerns.

There were policies and processes in place to keep people safe and safeguarded from abuse. The practice had a safeguarding lead for adults and children and all staff had completed safeguarding training to the required level for their role. The practice held a safeguarding register, and records we reviewed showed that they had been appropriately coded where safeguarding concerns had been identified. Clinical system alerts were used to identify people who were at risk of harm or abuse. There were processes in place to follow up children and young people who were not brought to their appointments both at the practice and for secondary care appointments.

During the clinical review we found people had not been provided with the appropriate care and treatment and their health needs were not being met.

Leaders told us they were part of a primary care network and regular meetings were held with services to understand and manage risks.

All staff were trained in basic life support and receptionists were aware of actions to take if they encountered a deteriorating or acutely unwell person and had been given guidance on identifying such people.

We found that processes needed to be strengthened to manage risks and ensure effective systems were in place for regular reviews. For example, there were registers to manage people prescribed high risk medicines and for those that had a long-term condition, however we found on reviewing the clinical system that people had not received the appropriate monitoring.

There were some processes in place to ensure the practice prioritised care for their most clinically vulnerable, however we were not assured that people were told when they needed to seek further help and what to do if their condition deteriorated. For example, our clinical searches found there were 4 people with a potential missed diagnosis of diabetes. We reviewed these clinical records and found the practice was not following best practice guidance and following these up appropriately. There were some systems in place to support people who face communication barriers to access treatment (including those who might be digitally excluded), however we found there was no hearing loop available at reception.

Leaders told us that that health and safety, security and maintenance of the building was regularly reviewed to ensure this was to a safe standard. All staff had completed health and safety training. Reception and administration staff who handled calls to the practice and arranged appointments with the clinical team were aware of potential red flag symptoms. Staff knew when to notify a GP or other clinicians with concerns about people who may be acutely unwell and/or deteriorating.

Annual checks of the environment had been completed, however we found actions had not been acted on. On the day of the assessment we found there was no hot water available for clinical staff to use. This had not been reported and staff were unaware of what actions to take. One of the leadership team was able to rectify the situation, however we had no assurances that there were effective processes in place to ensure all staff were aware of the processes in place when an incident arose.

During our site visit we found the premises were clean. There were a variety of processes in place to ensure the environment was safe which included a health and safety risk assessment and infection control audit, however, we found actions identified had not been acted on or were in the process of being completed. Fridge temperatures were recorded daily, and a data logger was in place which was reviewed regularly to ensure the fridge temperatures were within a safety range.

The practice had implemented a range of risk assessments to ensure the premises were safe, however we found that the actions identified had not been assigned to anyone for action or a review of risks had been completed to ensure the safety of the building. For example: we found wooden pallets had been identified as a fire risk and on the day of assessment the pallets were still being stored under the stairs. Another area that had been identified was the use of fan heaters. We found fan heaters still being used in the upstairs offices.

The practice had recruitment policies in place and all staff had completed disclosure and barring checks for all staff working in the practice and that all newly employed staff had completed an induction to ensure they were competent in carrying out their role. We found the practice had not ensured that staff working in clinical areas had received the appropriate training and monitoring to ensure they were competent in their role. On reviewing the clinical system we found that patients had received asthma reviews by staff who hadn't the competencies to carry out these reviews and had been signed off as competent by staff who had not been trained in long term condition management.

On speaking with the clinical team we were unable to gain assurances that there was a supervision of their clinical decision making, staff told us they were unaware if clinical supervision was in place.

There were staffing rotas to ensure there were adequate cover in place. On speaking with staff, we were told there were not enough staff on duty to cover busy periods and for staff absences.

Reception and administration staff who handled calls to the practice and arranged appointments with the clinical team were aware of potential red flag symptoms. Staff knew when to notify a GP or other clinicians with concerns about a patient who may be acutely unwell and/or deteriorating.

The processes in place for safe and effective staffing were inadequate with staff carrying out roles that they had not received the appropriate training for. On reviewing a random sample of clinical records with a coded history of asthma we found evidence to demonstrate that staff carrying out these reviews were untrained and unqualified. History and examination were not always adequate when the person was having an exacerbation and there was no follow up within 48 hours following the treatment of the exacerbation as recommended by clinical guidance.

We reviewed 4 personnel files and found appropriate checks such as previous employment record, proof of identity and clinical staff files had evidence to demonstrate that clinical registration checks had been completed. We found staff immunisation status records were in place for all staff except a newly employed member of the clinical team.

We found that supervision and oversight and staff in clinical roles was not effective, with staff unaware if clinical supervision was in place. Staff told us they had access to regular appraisals, however none of the areas they highlighted for development were addressed. ,

All staff had completed infection prevention and control training and were aware of the systems and processes to follow to ensure clinical specimens were handled safely. We were told that an infection control audit had been completed, however the leadership team were unaware of the outstanding actions the audit had identified.

We observed the general environment to be clean and tidy and cleaning rotas were in place. Sharps bins were available in all clinical rooms which were signed, dated, safely sited and were not over-filled. However, actions identified on the infection control audit completed in April 2024, showed new benches were required for the waiting area in reception. This had not been actioned and we found the chairs worn and torn in some places.

The practice had policies in place for infection, prevention and control which was accessible to staff and staff are aware of the action to take. For example, in the event of a sharps or contamination injury.

An infection control audit had been carried out in April 2024; the practice had achieved 98%. On reviewing the infection control action plan, we found that actions had not been completed.

We were informed that the curtains in the consultation rooms were changed annually. The practice were unaware of the recommended guidelines for privacy curtains to be changed every 6 months and no risk assessment was in place to ensure that risks had been reviewed and mitigated.

Results from the national patient survey demonstrated that 52% of people told us they have had enough support from local services or organisations in the last 12 months to help manage their long-term conditions or illnesses which was below local and national averages. However, the shortfalls we identified in relation to medicines management were impacting on people’s care. You can find more details of our concerns in the evidence category findings

The practice had employed a clinical pharmacist and also worked with the clinical pharmacist from the local Primary Care Network to identify prescribing and management of people receiving high risk medicines and medicines which required monitoring. We were not assured that there was clear oversight, as during the clinical review we found people on high risk medicines or long-term conditioning monitoring was overdue.

Our review of the clinical system highlighted that safety alerts were being acted on, however the practice needed to strengthen how people were contacted to ensure that they were aware of the potential issues and actions were acted on. Emergency medicines, vaccines and medical equipment had been reviewed and were appropriately stored with clear monitoring processes in place. There were appropriate arrangements in place for the management of vaccines and for maintaining the cold chain. We saw fridge temperatures were routinely monitored and vaccines reviewed at random were in date and stored appropriately. The practice held appropriate emergency equipment and emergency medicines which were checked on a regular basis. Vaccines were ordered and stored in accordance with national guidelines and the practice had systems in place to monitor the temperature of vaccine fridges.

We looked at patient group directives (PGDs - a legal framework that allows some registered health professionals to supply and/or administer specified medicines to a pre-defined group of patients, without them having to see a prescriber (such as a doctor or nurse prescriber). We saw that they had been authorised appropriately.

The practice had systems for monitoring two week wait referrals to ensure people were seen, however we were provided with no evidence to demonstrate that multidisciplinary meetings with other agencies were held to share and discuss information relating to patient care and treatment, for example, those on the practice palliative care register.

We found some improvements had been implemented to ensure workflow was followed up and actioned appropriately. However, on reviewing the clinical system we found people had not been provided with the appropriate care and treatment to ensure their health needs were being met. At the last assessment in May 2024 we identified 4 people as high risk that needed to be reviewed. At this assessment we still found there were outstanding actions or the appropriate monitoring had not been completed.

Clinicians did not always work with up-to-date evidence-based guidance, and we found that systems required strengthening to ensure processes such as a person's information including laboratory test results, monitoring and reviews were actioned in a timely manner. Our review of clinical records in relation to the clinical searches identified that care records was not always managed in line with guidance and legislation. Clinical searches of people's records were carried out as part of our assessment. We found 1087 people on the asthma register. The clinical search identified 47 people had been prescribed a course of 2 or more steroids in the last 12 months. We reviewed a random sample of 5 records and found 3 people had not been prescribed preventative inhalers, 2 had been prescribed the wrong dose of steroids and the clinical records contained inadequate history, ineffective reviews and no follow ups organised.

At the last assessment we found concerns in the management of high-risk medicines and the monitoring of medicines. During this assessment we carried out remote clinical searches and found some improvements with people who were prescribed high-risk medicines being monitored appropriately and action had been taken to ensure safe care and treatment was provided. We carried out a review of the number of people aged 65 years and above who were on non-steroidal anti inflammatory medicines who had not been prescribed the appropriate protection to reduce gastrointestinal difficulties. We identified a total of 7 people and reviewed a random sample of 5 records. We found 2 people had their medicines stopped for protection without any explanation as to the reason and no follow up had been organised. We found 1 person who was deemed as high risk who had not been reviewed following the latest blood results from October 2024. All people we reviewed required follow up.