Voyager Family Health

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 the last inspection, the provider was rated requires improvement due to the management of patients prescribed high risk medicines, emergency medicines and Medicines and Healthcare products Regulatory Agency (MHRA) safety alerts not being appropriately actioned. At this inspection we found that emergency medicines and equipment were suitable and easy to access. MHRA Alerts were being actioned. High risk medicines were being adequately monitored and patients with long term conditions had annual reviews, however the practice was aware it needed to strengthen its safety netting in ensuring patients attended for monitoring and reviews. The practice sent us their action plan detailing how patients were encouraged to attend annual reviews and any required tests by sending letters and reducing the number of medicines prescribed. We found there were systems and processes to ensure the premises were safe for use. There was a culture of learning including from incidents, complaints, and significant events. Processes to safeguard vulnerable adults and children from the risk of abuse were clear and well understood by all staff.

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.

People who used the service were listened to and their feedback was acted upon and used to drive improvement. Complaints were appropriately investigated whether they were formal written complaints or verbal. Complainants were provided with an explanation as to the findings of any investigation and an apology if this was required.

The provider listened to people’s views and responded proactively to make improvements to the service. The safety of people using the service was a priority. Staff were confident in their understanding about how to report significant events and confirmed learning and changes were shared with them in a timely manner. Leaders actively promoted the importance of reporting incidents and had an open culture of learning and candour with patients. The provider had clear and effective processes for staff to report incidents. When things went wrong, they were investigated, and changes were made that ensured the care and the quality of the service improved.

We noted an open culture in which all complaints were highly valued as being integral to learning and improvement. The provider had a complaints policy in place which clearly outlined the complaints process. The provider kept a record of all complaints received and any action taken because of complaints. Information and learning from complaints, incidents and significant events was shared across the team to improve patient experience. Regular meetings were held with standing agenda items on matters such as incidents and complaints. The learning from these were discussed and shared across the staff team.

Some comments received by CQC from Give Feedback on Care submissions were mixed about referrals or the practice receiving discharge information from other services. Some comments indicated that the systems were working as intended, others told us that there were delays in referrals or receiving discharge information from other services. The provider was aware that some discharge information was not readily available and, although out of their control, provided us with reassurance that this was monitored. The provider also informed us they kept up to date with the process for referrals as this changed for different services. Unless urgent they also had no control over the time frame people had to wait once a referral had been sent.

Staff involved with referrals were able to explain the processes which ensured continuity of care for patients. Staff explained that they had to continually check the processes for sending referrals as these could change depending on the service being referred to. This sometimes meant there was a delay for patients. Staff told us they attended regular multidisciplinary team meetings where patients who may be vulnerable or those receiving end of life care were discussed and actions agreed and put in place.

The provider worked with other agencies to ensure safe systems of care and treatment when patients were being supported by other services. Regular multi-disciplinary meetings were held and provided an opportunity to discuss patients with complex needs.

Referrals to specialist services were documented, contained the required information and there was a system to monitor delays in referrals. There was a process in place to check all patients with 2 week wait referrals had been referred appropriately and received their appointment with a specialist. There was a documented approach to the management of test results, and this was managed in a timely manner. There was cover in place when staff who carried out this role were absent. Reviews included patients requiring an annual chronic disease review. Invitations were sent via the communication platform, telephone or letter. Where possible this included self-book links. Our review of the remote searches of patient records showed that a small minority of patients with asthma who have had 2 or more courses of rescue steroids, were not followed appropriately. We reviewed 5 patient records and saw that attempts had been made to contact patients, but results were inconsistent. Leaders reassured us that the process would be further strengthened to mitigate the risks.

Feedback from people who used the service did not include any concerns with regards to safeguarding.

Staff could explain how safeguarding concerns were recognised and how this would be reported. Staff knew who the safeguarding leads were for vulnerable adults and children. Staff had been provided with safeguarding training at a level that was appropriate to their roles and responsibilities. Staff told us they were confident about what action to take if they had concerns about a patient’s safety and to report safeguarding concerns.

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

Alerts were added to the patient record system when a patient was subject to a safeguarding concern so that all relevant members of the staff team could readily identify this. Regular meetings were held within the practice where safeguarding was a standing agenda item for discussion. There were systems and processes in place when it was suspected that people may be subject to abuse or neglect. Up to date safeguarding policies were accessible to all staff. Recruitment checks had been carried out prior to employment including a Disclosure and Barring Service (DBS) check at the required level.

Results from the national GP Patient Survey 2024 showed that patients felt they were involved in their care and treatment the practice. Satisfaction levels were above the national and local averages.

Staff understood the role of involving people in making decisions about their care and treatment. Risks were identified and discussed with people and documented in the patient records such as do not attempt cardiovascular resuscitation (DNACPR) decisions. Staff told us they could easily access a clinician for advice about serious symptoms or where a patient was at risk of deterioration.

Our review of the remote searches of patient records showed that patients were informed about risks and how to keep themselves safe through safety-netting advice should their condition not improve or worsen.

Staff had been provided with training in health and safety related topics such as fire safety, infection control and moving and handling. Staff told us in discussions and feedback forms they were satisfied with the health and safety arrangements in the service. Staff told us there were quiet private spaces which could be offered to patients if they asked to speak privately with staff or felt overwhelmed in a crowded environment.

The service was located in a large building which had safe and appropriate access for people with a disability. There were sufficient rooms available to accommodate /host additional services. The premises were clean and contained the appropriate facilities to support infection prevention and control. There were adequate signage and clear fire escape routes and staff had been trained in the use of an emergency evacuation chair. During our visit we noted that one of the clinical rooms had been designed for the use of bariatric patients. This included the design of the room, equipment and furniture. Medicines and vaccines were stored securely, and they were readily accessible to staff who required them.

The practice used a facilities management company. There was regular communication with the company to ensure risks associated with the premises were identified and actioned. This included fire safety, general health and safety and legionella. There was evidence of up-to-date medical equipment calibration and Portable Appliance Testing (PAT) certificates were in place. There was a business continuity plan in place.

Patient feedback in the National GP Patient Survey 2024 indicated that patients were satisfied with the care and treatment they received from the staff team. For example, patients felt that they were listened to and treated with care and concern. Feedback we received directly from patients was positive and patients’ comments indicated high levels of satisfaction with members of the staffing team and the care and treatment they had received. However, we also received a small number of comments regarding staff attitude and not being able to see clinicians in a timely manner.

Staff received effective support, supervision and development to deliver safe care. They had regular appraisals and were able to discuss their development. Staff we spoke with told us there was a strong emphasis on development and all staff were encouraged to develop their skill base. We saw evidence of staff being upskilled to support their development and the practice. Leaders explained how they maintained oversight of staff training to ensure staff were appropriately trained and qualified to carry out their roles. We spoke with a wide range of staff members regarding staffing levels. All staff told us there was adequate staffing levels and there was always a manager or clinician to discuss any issues with.

Leaders monitored staffing levels within the practice and completed an annual review. We saw there was a mix of staff available to patients. This included nurses, nurse practitioners, phlebotomist, physicians associate, ST3s (ST3s doctors are in their final year of GP training) GPs and clinical pharmacists. All patients needing an on the day appointments were triaged by a GP before being offered an appointment at the Urgent Care Centre. Appointments were made with the most appropriate staff member. All staff worked to their skill competence and were supported by other clinical staff including the duty GP. The provider had appropriate recruitment processes in place. Including disclosure and barring (DBS) checks, references, induction and staff immunisation information. We reviewed training records and found staff had received mandatory training and training required for their role, which was up to date. Clinical staff had easy access to informal and formal clinical supervision. We noted there was a lack of formal auditing of prescribing for non-medical prescribers. This was discussed with leaders who immediately put in processes for performance monitoring of prescribing practices.

The feedback we received from patients prior to the inspection did not reflect any views regarding infection prevention and control.

Staff we spoke with had a clear understanding of the responsibilities in relation to managing the risk of infection within the premises. Staff knew who the infection prevention control (IPC) lead was and confirmed they were provided with training relevant to their own role.

On the day of inspection, we found the practice to be visibly clean and had appropriate personal protective equipment throughout the practice. We found posters around the practice including sharps injury, hand washing and clinical waste to support good practice. Cleaning schedules were in place and cleaning audits were carried out on a regular basis.

There were clear roles and responsibilities around infection prevention and control. There was an effective approach to assessing and managing the risk of infection, which was in line with current relevant national guidance. The provider completed regular hand washing and infection control audits, the results of these were actioned to improve compliance.

Feedback we received from people who used the service did not include any concerns related to the management of medicines.

Staff were knowledgeable about systems and processes within the practice that enabled positive patient care. Staff told of the process to ensure appropriate clinical oversight of test results. Regular searches and audits were in place to ensure the practice delivered timely reviews. Clinical staff were able to tell us about how they monitored patients’ health in relation to the use of medicines including high risk medicines. We interviewed leaders within the practice. We found there was a proactive approach to understanding the needs of different groups of patients and to deliver care in a way that meets those needs and promoted equality. This included patients who were in vulnerable circumstances or who had complex needs. They told us they prioritised safe, and compassionate care.

Fridges were being monitored and temperatures were recorded daily. Vaccines were appropriately stored and monitored in line with UK Health Security Agency (UKHSA) guidance to ensure they remained safe and effective. The practice held appropriate emergency medicines, and a system was in place to monitor stock levels and expiry dates. Staff had the appropriate authorisations to administer medicines including Patient Group Directions. We noted that emergency medicines now included a medicine used to treat symptoms of a low heart rate.

There was a process for the safe handling of requests for repeat medicines and medicines reviews. Patients were appropriately involved in decisions about their medicines. The provider had processes and clear audit trail for the management of information about changes to a patient’s medicines including changes made by other services. There was a process for monitoring patients’ health in relation to long term conditions and the use of medicines including high risk medicines. We saw evidence of appropriate monitoring and clinical review prior to prescribing. However, we identified a small number of patients who were overdue a review or monitoring, some due to the patient not attending required reviews. Patient records were well written and held up-to-date information about people’s care in line with current national guidance. There was a system for recording and acting on safety alerts. Minutes of meetings demonstrated clinical staff were kept up to date with any changes to guidelines and best practice. We saw evidence of audits to improve the quality of care and outcomes for patients. This included 2 cycle audits to demonstrate improvement had been sustained.

As part of the inspection, we conducted remote searches on the practice clinical system and reviewed a selection of patients’ records. Our review of the remote searches of patient records showed that most patients were being effectively and safely managed. Regular searches of the clinical record system were carried out for all patients who were prescribed high risk medicines. A small number of areas for improvement were noted. Our clinical searches found very low numbers of patients who had not had an annual review or monitoring for certain medications. However, we were assured by the practice and saw evidence, of an action plan to check for patients due their review and encourage non-compliant patients to attend for regular monitoring. These included ensuring all patients attended for required health checks prior to providing repeat prescriptions. Prescribing data for the practice showed no variation when compared to national averages.