Cradley 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

The practice had systems and processes in place to manage significant event and incidents. There were effective systems and processes in place to make sure people were protected from abuse and neglect. However, during our assessment of this key question, we identified two breaches of the legal regulation in relation to staffing and safe care and treatment. The patient toilet had no emergency call facilities available; legionella testing was not taking place; some actions identified from infection control audits were not carried out; the system for urine specimen collection required improvement and there was a lack of monitoring and oversight in relation to staff appraisals, staff personnel files and training.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People we spoke with said they were confident they would be treated with compassion and understanding if they were to raise a concern.

Staff were aware of their responsibilities and knew how to identify and report concerns and safety incidents. Significant event reporting forms were available to all staff to access on the practice computer system. Staff were able to share examples of incidents which had been investigated and actions identified.

The practice had systems and processes in place to manage significant event and incidents. The practice demonstrated how they investigated, identified learning and any improvements that were identified. The practice shared a meeting template which included significant events and incidents as a standing agenda. However, we did not find evidence of regular meetings taking place at the time of our assessment.

People told us when they were referred between services it was done in a coordinated manner.

Staff we spoke with told us about signposting and workflow regarding external healthcare services and the use of referrals. We found staff were knowledgeable in their role and were aware of support networks in the local area.

We did not receive any concerns from commissioners or other system partners about safe systems, pathways and transitions.

We found evidence of safety and continuity of care throughout the patient’s journey. There were systems and processes to share information with staff and other agencies to enable them to deliver safe care and treatment. This included regular multidisciplinary meetings between the practice and other health and social care professionals. The practice had appropriate processes in place for referral to secondary care and specialist services. We saw evidence these were documented, contained the required information and there was a system to monitor any delays. Audits were routinely undertaken to check all patients with 2 week wait referrals had been referred appropriately and received their appointment with a specialist.

We did not receive any concerns from people who used the service about safeguarding systems and processes.

Staff were trained to recognise the signs of abuse and were supported to take action by the safeguarding lead. Staff told us they knew how to recognise and raise a safeguarding concern.

We did not receive any concerns from commissioners or other system partners about safeguarding systems and processes.

There were effective systems and processes in place to make sure people were protected from abuse and neglect. The practice had a safeguarding policy and there was safeguarding information available for staff including identified leads and contact information. There were regular meetings between the practice and other health and social care professionals to support and protect adults and children at risk of significant harm. We saw posters in the waiting area which asked patients who may be experiencing domestic violence to alert the practice team.

Feedback we received from patients was positive regarding feeling involved in their care and treatment. Patients with long term conditions were provided with information and advice from the clinical team on how to manage their health and recognise when their health condition may be worsening.

Staff were appropriately trained in recognising the signs of sepsis. Within the practice we saw posters which provided information about sepsis.

The practice had an emergency procedures policy in place. Receptionists were aware of actions to take if they encountered a deteriorating or acutely unwell patient and had been given guidance on identifying such patients.

Staff told us they had the equipment required to perform their role.

We found the practice premises and equipment required improvement. There was level access throughout the practice for patients. Doors were wide enough to facilities wheelchairs, however, there was no automatic door to assist patients to access the building. We observed there was no doorbell facilities to alert staff if a patient with a disability needed assistance to gain access to the building. Parking at the practice was limited and patients parked across the road from the practice within a local car park. There was no designated disabled car parking space at the practice. The patient toilet had appropriate handrails but there were no emergency call facilities available. For patients with hearing impairments, there was no hearing loop system to assist them. Privacy curtains were used in consultation rooms; however, we observed one of the nurses’ rooms had a window which did not have adequate privacy as it had a window which allowed view from an external building.

The service conducted safety risk assessments such as fire, working at height and legionella (a term for a particular bacterium which can contaminate water systems in buildings). The practice’s health and safety policy stated, ‘ensure risk assessments are completed and any actions are implemented’, however the actions from the legionella risk assessment dated October 2023 had not been completed. The service undertook annual portable appliance testing (PAT Testing) and all medical equipment was re-calibrated annually.

People we spoke with told us they had support delivered by competent staff. Most patients we spoke with had been registered with the practice for several years and were very satisfied with the service they received from staff.

Staffing levels were sufficient to provide care and treatment. We did not see evidence of documented appraisals or clinical supervisions. Staff and leaders told us the appraisals needed updating but they were not currently taking place.

We reviewed 6 personnel files during the site visit and found recruitment checks for staff were not robust. For example, 4 out of 6 files did not have references, 2 out of 6 files did not have full employment history and 3 out of 6 files did not have completed induction checklist. We also observed gaps in mandatory training for staff. One person had not completed basic life support (BLS) training and there was no specific date on when this would be completed. One person had not completed training on fire, information governance or equality and diversity. The practice did not ensure staff received the support they needed to deliver safe care. We did not see any evidence of annual appraisals, documented meetings or formal arrangements for clinical supervision being undertaken for any of the staff files we reviewed.

People told us they had no concerns over the cleanliness of the practice. People told us they observed staff wearing disposable gloves during treatment and they saw staff washing their hands routinely.

Staff we spoke to were aware of who the infection prevention control (IPC) lead was. Staff told us that hot and cold water temperature checks were not taking place and therefore did not reduce the risks related to legionella bacteria.

The practice’s infection control handbook referenced this guidance: ‘Specimens received from patients should be placed in a rigid wipeable container,’ yet we observed there was a small cupboard in the patient toilet where patients were instructed to leave their samples. This was an infection control risk as the samples were not secure and could fall out of the cupboard. There was also an information governance risk of patient confidentiality and a risk children could access this cupboard. We also observed elbow taps were not available within one of the consulting rooms. This had been identified as part of a recent infection control audit but had not been actioned.

The practice had an IPC handbook which contained details of the IPC lead. The practice completed yearly IPC and hand washing audits. However, not all actions had been completed. The practice had a legionella risk assessment dated October 2023 which stated monthly hot and cold-water temperature checks were to be completed. However, we did not see evidence of legionella testing taking place.

People told us they received their medicines in a timely manner, and they felt involved in decisions about their medicines. They told us the clinical team explained their treatment and medication and made them aware of the risks, side effects and benefits of the medication.

Staff told us they were able to access the emergency equipment and emergency medicines easily.

The practice held appropriate emergency equipment and emergency medicines. Emergency equipment and medicines were checked on a regular basis. The practice ensured medicines were stored safely and securely with access restricted to authorised staff. Staff had the appropriate authorisations to administer medicines (including Patient Group Directions (PGD) or Patient Specific Directions). We reviewed a sample of PGDs and found these had been appropriately signed by staff and authorised by a GP. Vaccines were ordered, stored and transported in line with Public Health England (PHE) guidelines. Daily records of the maximum, minimum and current temperatures of the vaccine fridge were maintained. The practice had a data logger to assist in the monitoring of fridge temperatures.

The practice had a policy in place for the management of medicines, but our clinical searches showed this was not always effective. In response to our feedback, the practice developed new standard operating procedures (SOP) for the gaps we identified. For example, a new SOP was created for the monitoring of asthma which had been sent to staff to address this issue. There was a process for the safe handling of requests for repeat medicines. Blank prescriptions were kept securely, and their use was monitored in line with national guidance. The practice ensured every prescription was checked and verified by a GP.

With the consent of the practice, a CQC GP Specialist Advisor (GP SpA) accessed the practice's systems to undertake remote patient record clinical searches. These searches indicated a small number of patients were potentially at risk due to a lack of monitoring. We discussed our findings with the practice, and we saw evidence that they took immediate action to further investigate and follow up on these patients.