Holyhead Primary Healthcare 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 carried out an announced assessment of all 8 quality statements under the safe key question. We found that safety was a priority for everyone. Leaders had introduced an open-door culture that encouraged staff and patients to speak up when things went wrong. When people raised concerns about safety or ideas for change the primary response was to learn and improve continuously. Leaders were transparent in responding to complaints and apologised when it was necessary. A range of assessments had been undertaken to identify risks and mitigations were developed collaboratively to ensure patients, staff, equipment and premises remained safe. Services were planned and organised with people and communities at the centre to ensure effective care, efficient communication and safe transitions between care settings. People were supported to understand care information enabling them to make positive choices about their healthcare that minimised the risk of harm. Leaders ensured there were enough skilled staff to deliver safe care that promoted choice, control and individual wellbeing. Patients were provided with education and information that empowered them to take control of managing their own health. There were governance arrangements that protected staff and patients from risk of harm including the effective control and prevention of infection. The premises and equipment were appropriately risk assessed, maintained and monitored to ensure they were safe for use by patients and staff. Where we identified some issues with the management of clinical waste, storage of cleaning products, some clinical equipment and accessibility, leaders listened and took or planned action to address the problems. The practice used a range of searches and safeguards to ensure that medicines and blank prescription stationery was stored, used and disposed of safely. Medicines were prescribed and monitored in line with national guidance and safety alerts were monitored and actioned appropriately.

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.

From information we reviewed, we saw that the practice took complaints seriously and that people had the opportunity to speak to practice staff face-to-face about the outcome of the practice’s investigation into their complaint. People we spoke with when we visited the site told us they were not sure how to complain but felt confident it would be investigated if they did. We saw information about how to complain on the practice website, on notice boards and the television screen in the waiting room.

Staff were able to describe how patients could complain and the process of investigation that would be undertaken by the practice manager. Complaints could be made verbally or in writing by letter or email. The practice was open and honest about significant events (also known as learning events) which had occurred at the practice. Leaders created a culture which encouraged discussion, did not apportion blame and shared learning from such events. All staff were able to describe how learning events were reported and explained that learning outcomes were shared as a regular agenda item in the monthly clinical governance meeting. Staff had opportunities and were encouraged to provide feedback to leaders and share ideas for improvement. All the staff we spoke to said when they had done this action had been taken in response. The practice had a Freedom to Speak Up Guardian of whom all staff were aware. Staff were able to access a guardian within the Integrated Care Board (ICB) if they were not comfortable going to the practice guardian.

The practice had a complaints policy which had been reviewed in April 2024. There had been 8 complaints between 1 April 2023 and 31 March 2024. People who complained received a written acknowledgement within 3 days. On average all complaints were investigated and a response letter sent out within 30 days. We reviewed 2 complaints and saw that responses were personalised and if appropriate, people had been supported and offered further guidance on what action to take next. The practice reviewed complaint information and analysed any trends, using this information to inform future decision making. There were processes for staff to report incidents, near misses and safety events and for leaders to share information from learning events with all practice staff. This learning resulted in changes that improved care for others. If staff were not able to attend meetings, information relating to complaints and incidents was available to all staff electronically. There were 10 learning events recorded in 2023. We reviewed 2 of these and were able to see the process being followed from initially reporting, through investigation to learning and feedback. There was an up-to-date Freedom to Speak Up and Duty of Candour Policy which all staff knew how to access. Leaders monitored patient feedback from multiple sources and used this information to continue to develop and improve services. For example, patients reported in the 2023 national GP patient survey that they found it hard to access local services. In response the practice used their social prescribers to provide a range of local services on the practice site.

The 2024 national GP patient survey asked if patients had agreed a healthcare plan to manage their condition or illness with their healthcare professional; 75% of patients of this practice who responded said they had. This was higher than the local 49% and national average 45%. Of those people that responded to the survey, 21% of people reported that their last appointment resulted in a referral to specialist care, this was around the national average. When asked if they had received enough support from local services or organisations to help manage their conditions or illnesses, 56% reported that they had, this was below the national average of 68%. We found that the views of people who used the service, partners and staff were listened to and considered. Our observations raised no concerns.

We found that the practice had a strong focus on safety. Patients were able to request appointments with the same doctor for continuity of care and whenever possible these were accommodated. GP’s had follow-up slots that only they could book to provide continuity of care when they felt it was necessary The practice had effective and efficient processes to deal with referrals to specialist care. The practice had 3 General Practice Assistants (GPAs) and an administrative lead who were able to describe the procedures they followed to complete and send routine and 2 week wait referrals. Staff actively had oversight of the 2 week wait referrals and followed up if patients were not offered appointments. All clinical staff had clear referral pathways and lines of communication with external partners such as Health Visitors.

We were only able to gather limited evidence for this evidence category, however the evidence we did review gave no cause for concerns. We saw feedback that the practice had received from some clinical partners and their PCN colleagues which described positive working relationships and effective communication with Holyhead Primary Healthcare Centre staff.

Our review of patient’s records and the clinical system showed that letters, referrals and blood tests results were managed promptly and safely. The practice had effective systems for managing the information contained within discharge letters from specialist care including coding of new diagnoses, changes in medications and general practitioner follow up. A prioritisation system and electronic tasking ensured that doctors received the information and acted on it promptly. Test results were reviewed only by clinicians with administrative staff tasked to arrange any follow-up. We found administrative staff were trained in-house in the use of clinical coding and the GP partners reviewed and provided immediate feedback on the coding to ensure accuracy and consistency. We saw that urgent referrals were completed on the same day and routine referrals within 5 working days. We found the practice had effective processes for registering new patients, summarising their records and removing patients that were no longer registered at the practice. The practice had processes in place to ensure that a result had been received for every cervical screening sample sent off for analysis and to audit any inadequate samples. This information was communicated to the nursing team.

We could not collect the evidence to score this evidence category. Our observations raised no concerns regarding safeguarding at the service.

There was a thorough understanding and focus on safeguarding at the practice. All staff we spoke to were able to describe what would constitute a safeguarding concern, what actions they would take and what information they would record. Some staff were able to give specific examples and describe safeguarding actions they had taken to keep people protected.

The practice had received recognition from the PCN for their work in keeping people safeguarded. The ICB had carried out an audit of safeguarding knowledge, process and policy in September 2024 which the practice shared with us and which found no concerns. Feedback from the Health Visitor liaison for the practice showed there was regular information sharing.

The practice had both a named lead doctor and a dedicated administrative lead for adult and child safeguarding. We saw evidence that they met regularly with community staff such as Health Visitors and Social Workers to discuss patients who were on the practice safeguarding register. There were effective systems to make sure people were protected from abuse and neglect. Staff reviewed and updated the safeguarding register often and added electronic flags to the practice computer system for all family members of any patients on the register. We reviewed the practice’s safeguarding policies which were appropriate, comprehensive and up to date. The practice had processes in place to ensure that staff had completed training; a random sample of staff files we checked showed that all staff had up to date safeguarding training for children and adults at a level suitable for their role. The practice is IRIS accredited, this is a specialist domestic violence and abuse training, support and referral programme for general practices.

In the 2024 National GP patient survey 85% of people who responded said they were involved as much as they wanted to be in decisions about their care and treatment. This was slightly below the national average 91%. We spoke to 6 patients all of whom said they had been signposted to appropriate support by their doctor and had been given appropriate advice on how to manage changes in their condition.

The practice took an holistic approach to people’s care and several staff told us about planned and opportunistic health and lifestyle advice they provided to their patients. Staff told us the Healthcare Assistants (HCAs) ran an effective smoking cessation service which had performed the best across the West Midlands in the 1st & 2nd quarter of 2024 for patients achieving a 4 weeks quit . Holyhead Primary Healthcare Centre was the second best performing practice across the West Midlands in 2nd quarter of 2024 for patients acheiving a 12 week quit. The practice also ran a proactive Tuberculosis (TB) screening program contributing to early detection and management of TB. The practice had 2 part-time Social Prescribers who ran a comprehensive program of groups aimed at helping people to manage long-term conditions. Staff told us there was a balanced and proportionate approach to risk that supported patients and respected the choices they made about their care. Where patients had communication needs such as not having English as their first language, the practice had access to interpreter services including British Sign Language. All staff we spoke to were able to describe how to identify, assess and mitigate clinical risks.

From our record reviews we found that care plans were completed with patients and their carers. Reviews of long-term condition records indicated that reviews were thorough and patients were given safety-netting advice to deal with risks that may occur. The practice performed regular searches to identify people with a long-term condition who needed review and this enabled them to ensure they were kept current. We reviewed a random sample of Do Not Attempt Cardiopulmonary Resuscitation (DNA CPR) forms. We saw that staff had sensitive conversations with patients and their families about their needs and preferences. Staff followed suitable processes to assess patients’ mental capacity and to obtain informed consent. Leaders told us that regular home visits are scheduled for the palliative and end of life patients by dedicated GP's so that they have continuity of care and these patients were reviewed every 28 days. A dedicated HCA ensured the DNAR / CPR forms were reviewed regularly by the doctor. Paper copies of the forms were stored securely so they could be provided to paramedic staff in an emergency.

At the time of our assessment the lease of the building was still under negotiation and so leaders had limited powers to make changes. However, we saw a range of appropriate risk assessments relating to fire, health and safety and general maintenance. Although the building was quite old and did not appear to have been purpose built it was suitable and accessible. The practice had employed an external company to perform an accessibility assessment of the premises. The main finding of this assessment was the lack of an emergency alarm in the patient accessible toilet. The practice was able to show us a suitable risk assessment that was in place until the work could be undertaken to install the alarm later in the month of October 2024. The 2 storey building had ground and first floor with no lift. The first floor was accessible by a steep, narrow staircase that had handrails. There were 2 clinical rooms upstairs, used by the HCAs. The staff told us that if a patient had mobility issues the staff members would use a ground floor room for that appointment.

The premises were clean, well maintained and staff told us wheelchair users could navigate the building independently. There was a hearing loop available in reception. There was an accessible unisex patient toilet which had baby changing facilities and breastfeeding parents could use a clinical room. The waiting room was spacious enough to accommodate patient education groups as well as waiting patients. Clinic rooms were clean and the equipment was mostly fit for purpose although we saw fixed height couches in all the clinical rooms we assessed. These can present a health and safety issue for both staff and patients. The practice acknowledged the issue and provided their plans for gradual replacement as the couches wear out. The cupboard containing potentially hazardous cleaning fluid was on the first floor within the same room as the staff toilet but had no lock risking patients being able to access these substances. The practice provided evidence that the cupboard had a lock fitted the day after our assessment. We noted that the building was accessible but there were no automatic doors at the main entrance. Reception staff were unable to view the entire waiting room which could impact on patient safety. This risk was mitigated by CCTV in the waiting room. The CCTV was monitored by reception staff and the practice manager (we saw a small sign informing patients of this). We found no chairs in the waiting room with arms to assist those with mobility issues, staff rectified this immediately. We found some issues with the management of clinical waste for example the locked clinical waste bin was not secured to site and the gates to the car park were left open during the day. The practice took action to secure the bin to the site after our visit.

The practice had appropriate systems in place identify, assess and mitigate risks within the premises. Regular checks of the heating, electrical and water systems had been undertaken. We saw a range of suitable policies, audits and spot checks designed to maintain the safety, cleanliness and security of the building. We saw that all portable electrical equipment had been regularly tested. All clinical equipment had been recently calibrated. The practice carried out fire drills every 6 months and recorded attendance and actions arising. All staff had up to date fire safety training. There were designated fire marshals for each floor of the building. Firefighting equipment was available in appropriate places and had been serviced. The fire alarm system was tested weekly. The practice employed its own cleaner and the practice manager had an effective working relationship with them which provided managerial oversight.

In the 2024 National GP patient survey 92% of people who responded to the question said they had trust and confidence in their healthcare professional. People we spoke to said they felt there were enough staff and that they had sufficient skill and experience.

Before the assessment we received some anonymous information that suggested some people felt there were not enough doctors on site each day. However, when we reviewed the appointments system on random dates over the previous 4 months, we saw evidence that there were at least 3 doctors and 2 health care assistants (HCAs) on each date. All staff we spoke to had received an induction when they started their job, had annual appraisals and could access clinical support or mentoring when required. Staff who had specific non-patient facing extra roles such as the infection control lead were provided with dedicated time to complete these extra duties. We looked at a random sample of staff training records. All staff had completed their required mandatory training as well as specific training on Sepsis, Autism and Learning Disabilities. Staff reported they were given protected learning time to maintain their own professional development. The practice manager acknowledged they had struggled to recruit a permanent practice nurse and therefore qualified nursing cover was limited. The practice had 2 part-time long-term locum nurses who covered 3 days a week. The nursing staff were flexible and could offer occasional clinics at different days / times if required to accommodate patient need. The practice had healthcare assistants who undertook a wide range of health promotion work and ran a very successful smoking cessation clinic. All staff we spoke to understood the scope of their own and others roles.

The practice had effective processes to ensure they had the right number of staff and skill mix to support the safe and effective delivery of services. They had recently contracted an external company to undertake a capacity and demand analysis allowing them to understand how their appointments could be utilised to the best effect. 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, and training. There were policies to ensure staff with specific protected characteristics were not disadvantaged such as the equality and diversity and bullying and harassment policies. There were enough staff to provide appointments and prevent staff from working excessive hours. All administrative staff were trained in how to work on reception when required. We reviewed a random sample of staff records and found that the practice had fair and impartial recruitment methods. Enhanced Disclosure and Barring Service (DBS) checks were in place for all staff. The practice kept accurate records of staff immunisations. The practice had a system in place to monitor staff compliance with mandatory training and professional registration requirements.

Patients we spoke to said they found the practice to be clean including the toilet facilities. Our assessment did not provide any cause for concern in this regard.

A GP led on infection prevention and control (IPC), supported by an HCA who had been given specific IPC training. All staff that we spoke could describe their responsibilities regarding IPC and had been given appropriate levels of training. Staff told us IPC issues were discussed, reflected on and resolved in the monthly clinical governance meeting.

We observed that all areas of the practice were clean and clinic rooms were uncluttered to facilitate cleaning. Daily, signed cleaning logs were observed in all the clinical rooms we visited, cleaning materials, alcohol hand gel and suitable PPE was available. However, we found in some rooms that plastic aprons were stored loose hanging on a hook on the back of the clinic room door. This left them open to dust, dirt and contamination. The practice provided evidence 2 days after the assessment showing that wall mounted apron dispensers had been installed in every clinic room. We saw that in all the clinic rooms we assessed, the office chair for the clinician had a fabric covering which does not meet IPC standards for cleaning. Since our assessment the practice has ordered replacements with non-porous coverings. There were posters on hand washing technique in every clinic room and sinks all had suitable taps. On the day of the assessment there was no hot water in one of the upstairs clinic rooms, it was available in all other rooms and patient toilets. Pedal operated clinical waste bins were available in each room. The practice had 2 vaccine fridges which were fit for purpose, locked and the plug sockets could not be accidentally turned off. The fridges were clean, not overfilled and a random sample of stock we checked was in date. A spill kit (for cleaning spills of bodily fluids) was available at reception and in date.

The practice had a comprehensive IPC policy and an isolation policy to minimise the risk of transmission of communicable diseases. A random sample of staff records we checked showed all staff were up to date with a level of IPC training suitable for their role. We observed the rotas used by cleaning staff to ensure all areas were cleaned regularly including high and low areas and touch points. Where we observed fabric covered office chairs, the practice provided us with evidence of how these chairs were cleaned as they were not wipeable. Regular IPC audits were carried out and we were shown the resulting action plans. All actions had been completed within a suitable timeframe. All staff were trained in how to manage the cold chain to ensure the safety of vaccines. There was a policy in place to manage any breaches of the cold chain and staff were familiar with the contents. Any breaches that occurred and the learning resulting from them were shared at the clinical governance meeting. The practice had a clinical waste management protocol which was updated following our assessment to reflect required changes including labelling of bags with the practice name and address and securing the clinical waste bin to site.

Staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely. People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms. Of those people that responded to the 2024 National GP patient survey, 85% felt their needs were met at their last appointment which is slightly below the national average of 90%. All the patients we spoke to during the onsite visit said it was easy to order repeat prescriptions of their medications. Our assessment found no cause for concern in this regard.

Staff and leaders described the processes they had implemented to ensure that medicines and treatments were safe and met people’s needs. Staff told us patients were involved in decisions about their treatment and supported to manage their medications effectively. The practice had a pharmacist (employed by the PCN) who carried out regular medication reviews for patients on long-term medications and ensured that patients on high-risk drugs such as disease-modifying anti-rheumatic drugs (DMARDs) had the appropriate monitoring. The pharmacist reported that they performed regular searches of the clinical systems to identify which patients required review or monitoring. Staff felt confident managing the storage, administration and recording of medicines. Staff followed protocols to ensure they prescribed all medicines safely, and ensured people received recommended medicines reviews and monitoring.

We saw that staff managed medicines safely. Medicines were ordered, stored, used and disposed of appropriately. Vaccines were stored in specific vaccine fridges which had regular manual and electronic temperature monitoring. Staff knew what process to follow if the temperature was out of the acceptable range. Stock was rotated to ensure use before expiry. We looked at a random sample of vaccines within the fridges and found them all to be in date. We viewed a random sample of other single-use items or equipment with expiry dates and found them all to be in date. In the clinic rooms used by HCAs urinalysis bottles (used to collect a urine sample for testing) from a variety of batches were mixed in a drawer. This risked using a bottle that was past its expiry date or wasting stock because it was not clear which bottles were due to expire. The practice took immediate action to separate batches. We assessed the emergency medicines the practice held. We found some medicines were not available such as an injectable form of a non-steroidal anti-inflammatory for pain relief a nd there were no risk assessments in place to explain why the decision not to keep them as emergency drugs had been taken. The emergency medicines and equipment were all stored in a clinical room but in separate places and some medicines were stored in an unlocked cupboard. The provider sent us evidence, to show, following the onsite visit, they had ordered appropriate emergency medicines and a risk assessment was produced for medicines they had chosen not to keep on site. The emergency medicines and equipment were moved into a more accessible but secure location. Medical gases such as oxygen were stored in a clinic room that did not have a warning sign. This was rectified during our visit.

The practice had an up to date, comprehensive medicines management policy. This clearly detailed the processes patients and staff followed when ordering and prescribing repeat medicines. If patients were due for monitoring or review or were not compliant with either of these the policy laid out how the practice staff would manage these situations. Nurses who administered vaccines did so under Patient Group Directives (PGD’s). PGD’s allow specified health professionals to supply and/or administer medicine without a prescription or an instruction from a prescriber. We saw that all PGD’s for the practice were within date and signed by the relevant staff. Healthcare Assistants who administered vaccines did so under a Patient Specific Directive (PSD). PSDs are written instructions, signed by a prescriber, for medicines to be supplied and/or administered to a named patient after the prescriber has assessed the patient on an individual basis. We saw examples of PSD’s used by the practice which were satisfactory although they did not include details about the frequency of vaccination or the route of administration. Policies were available to staff covering both types of directives. The practice had a clear process for monitoring and performing medication reviews. Alerts from the Medicines and Healthcare products Regulatory Agency (MHRA) were monitored, circulated to all staff and actioned by the Pharmacist. There were robust processes to contact all patients affected by an alert and to advise, change or stop medication as required. Blank prescription stationery was held on the premises securely and the practice had clear systems for auditing prescription stationery use.

People’s medicines were appropriately prescribed, supplied and administered in line with the relevant legislation, current national guidance or best available evidence, and in line with the Mental Capacity Act 2005. The ICB had recently carried out an audit of antibiotic prescribing practices which correlated with data we viewed as part of our assessment and showed safe prescribing levels and adequate antimicrobial stewardship. We carried out a variety of searches of the practice clinical records. Our searches indicated the provider had a comprehensive approach to medicines management.