Delapre 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

We assessed all the quality statements for this key question. Our rating for this key question has improved from inadequate to good. During the assessment we reviewed policies, spoke with staff via video conferencing, and undertook observations while on site. We completed remote clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements). We reviewed patient records to identify issues and clarify actions taken by the provider. The practice had systems for the appropriate and safe use of medicines, including medicines optimisation. We found the practice had systems and policies in place for recording and acting on significant events and complaints and to ensure compliance with the requirements of the duty of candour. Learning was shared effectively and used to make improvements. We found improvements had been made to the systems and processes within the practice and actions had been taken in response to risk assessments. .

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We could not collect evidence from patient feedback to score this evidence category. Our observations raised no concerns. The evidence we reviewed did not show any concerns about people’s experience regarding the learning culture at this practice.

Significant events and complaints are well managed with learning identified and shared. Staff reported they were able to raise concerns and attended meetings where learning from significant events and complaints were discussed. Managers encouraged staff to raise concerns when things went wrong.

The provider had policies and processes in place for staff to report incidents, near misses and safety events. There were systems in place to ensure concerns were listened to and reported on. These were then investigated and reviewed and all outcomes shared with staff to reduce the likelihood of the incident reoccurring. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Staff meetings were held where significant events and complaints were discussed.

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

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 such as health visitors, community midwives and social workers.

There were identified safeguarding leads within the practice. Staff were aware of the safeguarding leads and could access additional information within the practice to support them in taking action as required. Staff we spoke with informed us of appropriate actions taken when safeguarding concerns were identified. Minutes of safeguarding meetings were accessible to all staff.

Safeguarding systems, processes and practices were developed, implemented and communicated to staff. Clinicians and staff were trained to appropriate levels for their role. There were systems to identify vulnerable patients on records. Disclosure and Barring Service (DBS) checks were undertaken when required. We gained remote access to patient records and found no risk associated with patients on the safeguarding register.

Staff told us that people were informed about any risks and how to keep themselves safe through their treatment of conditions. Leaders told us about systems to regularly review consultations to ensure risks were managed whilst respecting patient choice. Staff reported they felt supported when making decisions about patient care. A designated GP was available daily for staff to access for support and advice.

Systems were in place to support people to be as involved as they could be to understand and manage risks to their own health, safety and well-being. This was demonstrated through our remote clinical searches which looked at medication reviews, prescribing and adherence to medicine alerts. The clinicians worked with social prescribers and mental health nurses to signpost patients to relevant support as well as meeting their clinical needs.

Action had been taken following the previous inspection, in July 2023, to ensure health and safety risk assessments had been carried out and appropriate actions taken. Staff reported they were involved in making improvements.

The systems and technology the practice used were appropriate and equipment was regularly checked to be safe. The facilities and equipment supported the delivery of safe care.

Risk assessments were in place to mitigate risks within the premises. For example, fire, legionella and oxygen. There was also a system of carrying out regular safety checks such as gas and electricity safety and calibration of medical devices. There were effective arrangements to monitor the safety and upkeep of the premises.

Leaders explained their recruitment processes to support the delivery of consistently safe, good quality care that met the needs of the patient population. Leaders informed us that staffing was reviewed at the weekly partners meetings to ensure sufficient appropriate numbers of staff were employed. They reported that there had been a reduction in staff turnover in the past year. Staff vaccination was maintained in line with current UK Health and Security Agency (UKHSA) guidance if relevant to role.

There were various policies related to the management of the practice to help maintain a safe and effective workforce. This included recruitment, appraisal, supervision, incident reporting, performance management and training. We reviewed training records and found all staff were up to date with their training. Staff records demonstrated appropriate recruitment processes had been followed. Processes were in place for the support and oversight of non-medical prescribers.

We could not collect evidence from patient feedback to score this evidence category. Our observations raised no concerns. The evidence we reviewed did not show any concerns about people’s experience regarding infection prevention and control at this practice.

Leaders informed us there was an identified infection prevention and control (IPC) lead in the practice. They had been supported by the local Northamptonshire Integrated Care Board (ICB) to make improvements to IPC measures in the practice. Staff had received IPC training and were aware of who the IPC lead was and how to report concerns.

The practice was visually clean and tidy on the day of our assessment. Staff had access to personal protective equipment and clinical waste was stored and disposed of appropriately. Sharps bins were correctly assembled and stored. They had been signed and dated appropriately. Privacy curtains were changed regularly with the date of this recorded.

The practice had policies in place for IPC, clinical waste and sharps management. These were available for all staff to access. An IPC audit had been completed in May 2024 and actions had been taken in response to the findings.

Staff received training on medicines management, and felt confident managing the storage, administration and recording of medicines. Staff managed medicines-related stationery appropriately and securely. Staff followed protocols to ensure they prescribed all medicines safely, and ensured people received all recommended medicines reviews and monitoring.

A remote review of the patient clinical record system demonstrated that action had been taken following the inspection in July 2023. We observed work had been done over time to ensure appropriate monitoring and reviews had taken place. Medicines were stored safely and securely with access restricted to authorised staff. Blank prescriptions were kept securely, and their use monitored in line with national guidance. Staff had the appropriate authorisations to administer medicines including Patient Group Directions or Patient Specific Directions. The practice held appropriate emergency medicines and systems ensured stock levels and expiry dates were monitored. There was medical oxygen and a defibrillator on site and systems to ensure these were regularly checked and fit for use. Vaccines were appropriately stored, monitored and transported in line with UKHSA guidance to ensure they remained safe and effective. The practice could demonstrate the prescribing competence of non-medical prescribers, and there was a regular review of their prescribing practice supported by annual appraisals, clinical supervision and training.

There was a process for monitoring patients’ health in relation to the use of medicines including medicines that required monitoring (for example, warfarin, methotrexate and lithium) with appropriate monitoring and clinical review prior to prescribing. The practice had a system for recording and acting on safety alerts. We carried out a remote review of the clinical record system and found in general appropriate actions had been taken in response to safety alerts received.

Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. There was a programme of regular clinical auditing of prescribing that focused on improving care and treatment. The remote review of patients who were prescribed medicines that required monitoring demonstrated the majority of patients received appropriate blood monitoring prior to medicines being prescribed. Our searches did identify a minority of patients who were overdue a review of their medicines. Immediately following the assessment the practice provided evidence that these patients had been contacted for a review.