Brierley Park Medical Group

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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment, we rated this key question as good. At this assessment, the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. The service was in breach of legal regulations in relation to safe care and treatment and fit and proper persons employed.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. People were supported to raise concerns and staff treated them with compassion and understanding. A representative from the Patient Participation Group (PPG) felt the provider took concerns seriously and proactively made improvements to the service. For example, the practice had gathered feedback from people that attended a menopause event, arranged by the PPG, and used this feedback to establish a monthly menopause clinic within the practice. Managers encouraged staff to raise concerns when things went wrong. Staff felt there was an open culture, and that safety was a top priority. 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.

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.

Safeguarding policies were in place and known to staff who were appropriately trained in safeguarding procedures. However, the safeguarding policies did not highlight the risks associated with modern slavery or human trafficking. Following our assessment, the provider forwarded to us an updated policy that included this. The practice maintained a list of vulnerable people and acted on concerns by working in partnership with other organisations. The service worked with people and health and social care partners to understand what being safe meant to people and the best way to achieve that. Safeguarding meetings were used to raise awareness of potentially vulnerable groups of people, for example children that were home educated. There were systems in place to follow up people who failed to attend important appointments in primary and secondary care or, were frequent attenders to the emergency department.

The service worked with people to understand and manage risks. It provided care to meet people’s needs that was safe and supportive. Appropriate emergency equipment and medicines were available within the practice and systems were in place to check them regularly. Staff could recognise a deteriorating person and knew the action to take. People were advised on risks related to their condition and the actions to take if their condition deteriorated.

The service did not always detect and control potential risks in the care environment. They did not always make sure equipment and facilities supported the delivery of safe care. Some health and safety risk assessments and audits had been undertaken. However, action plans were not in place to address concerns identified in some of the risk assessments for the branch practice which the provider took over 17 months ago. For example, the fire risk assessment and the electrical installation condition report which was rated unsatisfactory. The provider told us they would address this with the landlord of the building. The provider did not have a fire risk assessment for the main practice. Electrical equipment had been calibrated and tested however, a full inventory of electrical equipment had not been completed to ensure that all of the electrical equipment within the practice was regularly safety checked. This had been highlighted in the learning from a significant event. The provider planned to complete the inventory by May 2025. There was a business continuity plan in place which was monitored and reviewed.

Safe recruitment practices were not always followed. The practice’s recruitment policy did not include all of the legally required staff checks. For example, photographic identification, checking for gaps in employment histories or physical and mental health assessment prior to commencing work at the practice. A review of staff records during our onsite assessment supported this. The practice immediately updated staff records with photographic identification. Following our assessment, they forwarded to us an updated recruitment policy. All of the required staff immunisations or immunity status for hepatitis B were not available in the staff files we reviewed. Risk assessments had not been completed to mitigate potential risks despite this being identified in the service’s infection prevention and control audit which was completed in July 2024. However, the service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. Where gaps were identified, staff had been recruited to fill them. Staff worked well together to provide safe care that met people’s individual needs. There were a range of clinical and non-clinical roles within the practice. We found training was mostly up to date, learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. There was a designated infection, prevention and control (IPC) lead who staff were aware of. Staff had received relevant training in IPC. Risk assessments and audits were completed, and action plans were in place to mitigate potential risks. Completed cleaning schedules were not available within the practice to enable the provider to monitor that cleaning had been completed as required. However, twice monthly spot checks were completed by the cleaning company and areas identified where improvements needed to be made.

The service did not always ensure medicines and treatments were safe or met people’s needs. Processes for monitoring people’s health in relation to the use of medicines that required blood test monitoring, for example medicines used in the prevention of blood clots, were not always effective. National prescribing guidance was not always followed such as, follow up within 48 hours of people prescribed medicines for an exacerbation of asthma or medicines used for the treatment of nerve pain. People with a potential missed diagnosis of chronic kidney disease had not always been appropriately followed up. Medicines and Healthcare Products Regulatory Agency alerts were not always adhered to such as, risks associated with medicines used in the treatment of diabetes. Prescribing policies did not clearly demonstrate the practice’s processes to mitigate these potential risks. After our assessment, the service forwarded to us an action plan to show how this would be addressed and told us that the issues partly related to historic issues at the branch practice they took over in 2023. Systems for tracking prescription stationery throughout the practice were not in place. After our assessment the provider informed us of how this would done. Non-medical prescribers received regular training and support however, regular competency checks had not been completed. Following our assessment, leaders told us they would carry out a 3-monthly prescribing audit cycle. Some medicines were not always stored securely. Test results and documents were not always handled in a timely manner. However, effective systems were in place for checking the expiry dates of medicines. Medical gases were stored safely. 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. Staff involved people in reviews of their medicines.