All Saints Medical Centre PMS

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 found the service was providing safe services because the provider carried out risk assessments and we saw evidence the provider had taken action to ensure the environment was safe for staff, patients and visitors. However, the provider had not formally recorded the actions taken as a result of risks identified through risk assessments. The premises was clean and tidy and the practice organised multidisciplinary team meetings to ensure patients were safe. We found improvements were required to the practice’s emergency equipment, in particular, the practice did not hold a set of paediatric defibrillator pads.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice had incident management and complaints policies which stated complaints and incidents would be reviewed regularly. We saw that significant events were a standard agenda item in practice meetings.

Staff told us they attended meetings where significant events were discussed, and learning shared from review of incidents. The provider had recorded 13 significant events in the last 12 months. Staff were able to share examples of where improvements had been made as a result of significant events. For example, a patient was given the paperwork relating to a different patient. Staff were reminded to take more than one piece of identifying personal information from a patient before providing information. However, the practice did not always identify and evidence the learning needs which arose from complaints. The practice stated that they would introduce a section in the recording of complaints which would be implemented moving forward.

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.

The provider shared copies of fire, health and safety, and legionella risk assessments, all of which had been completed in January 2024. Recommendations were made as a result of these risk assessments, including some described as high risk. The provider told us all recommendations had been completed and we saw evidence of actions taken as a result of the risk assessments during the site visit. The practice’s fire safety policy named 3 staff members named as fire officer, deputy fire officer and fire marshal/officer. However, we did not see evidence that these staff members had completed fire marshal training. Following our site visit, the provider sent evidence that 2 members of staff had completed fire marshal training after our assessment. The practice did not hold paediatric defibrillator pads. We discussed our findings with the provider who told us they would look to purchase some. Following our inspection the provider told us they were unable to purchase paediatric defibrillator pads due to a lack of stock.

We observed that recommendations from health and safety, legionella and fire risk assessments had been completed. However, there were no formal action plans to accompany the audits. We looked at the equipment and medicines held by the practice to enable them to respond to emergencies. There was an inventory and evidence of regular monitoring of medicines and equipment. We found the practice did not hold paediatric defibrillator pads. The provider had not assessed the risk to patients of not holding paediatric defibrillator pads onsite. We saw evidence that testing of the practice’s fire alarm system took place each month. The last fire drill took place on 15 January 2024.

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

We saw records that showed an infection prevention and control audit had been completed in January 2024. Recommendations were made as a result of this audit and we saw actions had been completed. The provider told us there was a remaining action, relating to peeling and chipped paintwork in clinical rooms, and this would be completed by June 2024. However, there was no formal action plan to accompany the audit.

The practice had completed an infection prevention and control audit in January 2024 and had taken action following recommendations made in the Legionella risk assessment. An action plan accompanied the Legionella risk assessment, which the practice were completing.

We observed the premises to be clean and tidy. Clinical waste was kept in a secure area and there were arrangements in place for regular waste collection. There was a designated room for cleaning equipment. We found this cleaning cupboard to be locked and well maintained. Personal protective equipment (PPE) was available for use in all clinical rooms.

We found patients prescribed a medicine to treat autoimmune conditions were monitored in line with best practice guidance. We saw patients received regular medicine reviews. Our searches suggested some patients had not had the required monitoring tests. We reviewed 5 patients in detail and found 4 patients were overdue monitoring tests. We shared our findings with the provider who arranged for all the patients identified in our searches to be contacted for monitoring tests. We reviewed patients prescribed a type of medicine used to lower blood glucose. This medicine had an associated safety alert meaning patients should be informed of risks associated with this medicine. Our searches indicated some patients had not been fully informed of the risks. We reviewed 5 patients in detail and found here was no evidence 4 of these patients had been fully informed of the risks. We shared out findings with the provider who arranged for information letters to be sent to all patients prescribed this medicine.

The provider had a medicines management policy and a safety alert protocol. However, our clinical searches found actions associated with safety alerts were not always fully completed. Following our assessment, we saw evidence the provider had taken action to ensure patients were informed of risks associated with medicines where necessary.

The practice completed annual reviews for patients with disabilities and patients were offered home visits where indicated. The practice held quarterly palliative care meetings alongside the end of life care lead nurse, district nurses and the hospice. The practice completed a two-cycle audit for patients prescribed direct oral anti-coagulation medicines to ascertain if these patients had up to date renal function monitoring. The practice had demonstrated improvements in their monitoring of these patients by introducing maximum repeat prescriptions and appropriate prompting on the electronic clinical records system.