Shipley Medical Centre Also known as Affinity Care

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

During this focused assessment we found that the practice provided safe care and treatment for patients. At our last inspection of the service in December 2022, the provider was rated requires improvement for the provision of safe services. We saw at this latest assessment that the provider had made improvements which included embedding processes for monitoring and reviewing patients in receipt of high-risk drugs, ensuring processes were in place to receive and action patient safety alerts, and monitoring clinical tasks to ensure these had been actioned. The provider had also made progress regarding establishing the vaccination status of staff, but this still needed to be completed. We saw that safety issues were managed effectively, and had high level oversight via a dedicated Quality and Safety Group which reported to the Board of Directors. We saw that the provider had developed and implemented comprehensive clinical supervision processes, and had improved their approach to learning after incidents and significant events, which enhanced safety within the practice.

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 received only limited patient feedback regarding peoples experience related to the learning culture of Shipley Medical Centre. An issue was highlighted with us which indicated an inability to contact the practice regarding a complaint, which was later resolved. We saw that details of how to complain were available by contacting the practice directly in writing, verbally, or via the practice website.

Leaders at the practice told us that they had established processes to improve services based on learning from significant events and adverse incidents, complaints, audit findings, or other feedback. Staff we spoke with, or received feedback from, confirmed that they knew how to identify and report significant events and incidents, and that any reported had been subsequently investigated, and actions taken as a result. Staff said that they felt free to raise concerns with leaders and managers without recrimination. Staff confirmed to us that they were also aware how to record and handle patient complaints. They told us that, if possible, they would attempt to resolve complaints immediately, but if this was not possible, that these would be formally recorded and reported for investigation. We saw that learning events were discussed at team meetings, and when required raised with individual staff members.

The provider had developed and implemented policies and processes for complaints, significant events and incidents, and quality improvement. These were available to staff on the shared information access platform at the practice. Staff told us that they felt confident that incidents reported would be investigated and actioned when required. We saw over the previous 12 months that the provider had recorded 201 incidents and events, and 60 complaints. We saw that complaints and incidents were investigated, and that any themes or learning identified were used to improve services. For example, incidents regarding prescribing errors were fed back to teams to promote learning, and any errors were rectified. The provider had developed mechanisms to ensure that reflection and shared learning from events had been undertaken prior to closing the incident. This included via a regular quarterly quality and safety bulletin, and in meetings. The provider had effective oversight of both learning events and complaints, and these were discussed at a Quality and Safety Group which met quarterly, and which further reported to the organisation’s Board of Directors. The provider had appointed senior staff members from their clinical, pharmacy, and administration teams to lead on complaints and significant events.

We saw no indication of concern in this area.

Leaders, managers and staff told us that they worked with others to develop and maintain safe and responsive systems of care for patients. The provider informed us that all staff were required to use a standardised referral process and template to facilitate this. Clinical updates were given at specific sessions to train clinical staff in the use and navigation of this template, as well as giving specific clinical updates on how manage particular conditions, and when to make referrals. Updates were given each year for respiratory disease, cardiovascular disease, diabetes and cardiometabolic disease as these clinical risk areas aligned with particular health needs and outcomes within the practice population.

We received no feedback from partners and stakeholders regarding safe systems, pathways and transitions for the provider.

The provider had established detailed processes for managing pathways and transitions of patients through care and treatment. The provider used a standardised referral process and template which was managed by their local Integrated Care Board. This ensured that any changes to referral pathways were consistently updated to match local guidelines and service capabilities. The provider also had other processes in place to assess and support patients who had been discharged from hospital, or who required changes to their medication following secondary care treatment. For example, if medication changes were needed this was sent for reconciliation to the pharmacy team for actioning. If newly discharged patients came under the provider’s home visiting team, their record was flagged with the team for their attention and awareness.

We saw no indication of concern in this area.

We heard from leaders and managers, that systems, processes and practices had been developed and implemented by the provider to ensure that patients were safeguarded. Staff we spoke with were clear on how to recognise and raise a safeguarding concern. Staff told us that they had received safeguarding training appropriate to their role, and this was corroborated when we checked staff training records. The provider had appointed a senior staff member to act as the safeguarding lead for children and adults across Affinity Care, and individual leads had been put in place across each locality. Safeguarding leads attended Bradford safeguarding meetings to discuss vulnerable patients.

We received no feedback from partners and stakeholders regarding the provider in respect to safeguarding.

The provider had established processes to identify, record and action safeguarding concerns. This included the development of safeguarding policies and procedures, and dedicated time to discuss safeguarding during meetings. Both children’s and adult’s safeguarding policies had recently been reviewed in August 2024 and October 2024 respectively. Safeguarding concerns were discussed at a range of internal meetings. These included the weekly Shipley locality multidisciplinary team meeting, the home visiting team meeting, and the care homes meeting, as well as external safeguarding meetings. Safeguarding practice was also monitored by the Affinity Care Quality and Safety Group, and audits had been undertaken of key safeguarding performance areas. Staff had received equality and diversity training, learning disability and autism awareness training, and when appropriate to their role training in mental capacity and the Deprivation of Liberty Safeguards. We saw training attainment in these areas was actively monitored.

Patient feedback from the 2024 National GP Patient Survey indicated that patient satisfaction with how the practice worked with them to manage their care and treatment was generally in line with local and national averages. For example, 93% of respondents reported that they were involved as much as they wanted to be in decisions about their own care and treatment during their last general practice appointment, compared to local and national averages of 91%.

We heard from leaders, managers and staff that they worked with patients to help them understand and manage risks so that their needs were better met. For example, they told us that if required they would use translation and interpretation services to better communicate with patients. We were told that staff from the practice worked with other care and health professionals to review and deliver appropriate patient care and treatment. Staff were aware of advanced care planning and referral routes should additional support for patients be required. Staff told us that when patients had been referred to other services, that they tracked these referrals. Staff informed us that they were aware of how to identify and intervene should they feel a patient’s health be deteriorating whilst in the practice, and confirmed to us that emergency procedures were in place. This included calling the available duty doctor and accessing emergency medicines and equipment.

The provider had processes in place to inform patients and involve them in the management of risks associated with their care. For example, all patients (of child-bearing age) prescribed teratogenic medicines (medicines which may affect a developing foetus) had been issued with letters, which informed them of the risks associated with this type of medication during pregnancy. In addition, the provider had processes in place for staff to actively engage with parents who were reticent to put forward their child and participate in the child vaccination programme.

Leaders and managers told us that they had developed and adopted health and safety management processes which ensured the safety and wellbeing of patients, staff and visitors to the practice. Staff informed us that they had undertaken required mandatory training in respect of health and safety, such as annual fire safety training. Staff told us that they had no concerns related to health and safety in the practice. They confirmed that fire alarm tests and emergency evacuation drills had been undertaken and this was supported by records we examined as part of our assessment.

We saw that the physical condition of both sites operated by the practice was generally satisfactory. From checks of records, and observations we made on the day of our visit, we saw that equipment had been maintained, and when required had been calibrated to ensure effective operation. Cleaning and disinfection regimes were in place, and necessary health and safety measures were in place for the safe use of these cleaning materials and equipment. The provider had medicines and equipment in place to deal with medical emergencies, and we saw that these had been regularly checked to ensure they were fit for use.

The provider had management processes in place which gave assurance that health, safety and wellbeing requirements were met. For example, a fire risk assessment had been undertaken in July 2023. We saw evidence which showed that areas of non-compliance highlighted in the assessment had been actioned. For examples, the assessment had highlighted that some fire doors had been wedged open. Following this adverse finding, these had been removed. The provider ensured that fire equipment and lifts had been subject to regular maintenance and testing.

We saw no indication of any concern in this area.

Leaders and managers told us that staffing levels were monitored, and that rotas were in place which ensured that there was the right mix of staff numbers and skills in place to deliver safe and effective care. When additional capacity was required, we were informed that recruitment would be undertaken, additional hours would be made available to staff, or agency staff and locums would be engaged. When we discussed staffing levels with existing personnel, they told us that they felt staffing levels were sufficient. Both leaders and managers told us that they sought to improve capacity and effectiveness by supporting staff to attain additional qualifications. Staff we spoke with told us that when joining the practice, they had received induction, and were required to complete necessary mandatory training such as fire safety. Clinical staff also informed us that they were subject to sessional debriefings, and checks on prescribing. Staff also informed us that they found senior clinicians and line managers approachable, and that they were willing to advise them when additional support was required. Other information and guidance was available to staff on the provider’s intranet.

The provider had developed a recruitment policy, however this had not been reviewed in the last 12 months. Recruitment checks had generally been carried out in accordance with regulations. However, we found that records were difficult to readily access as information was held on different parts of the IT system. The provider told us that they had recognised this issue and were moving to a new integrated system in the near future. We saw that the provider had made progress in assessing the vaccination and immunisation status of staff. Induction processes were in place for newly appointed staff including locums. For example, the practice had developed detailed preceptorship (a period of structured transition to guide and support newly appointed staff) for healthcare assistants. The provider had also developed processes to manage clinical supervision. We found this approach to give high assurance that non-medical prescribers, newly qualified GPs, and other relevant staff received the level of support and supervision required to give assurance that the care and treatment they provided was done competently. Newly qualified prescribers and physician associates had a dedicated GP mentor to support them in their role. There was an allocated debrief GP available daily and a system in place to ensure appropriate support and oversight. For example, debriefs for all patients prior to them leaving the practice initially, then a move to end of surgery debriefs when staff member and supervising clinician are comfortable to do so. The provider had developed a template within the clinical system in which any changes or additional information could be recorded by the supervising GP. Clinical supervision was fully documented, and responsibility for implementing this process across Affinity Care was held by the medical director, with local oversight by locality directors. Staff safety, effectiveness and competency was also supported by a programme of clinical and non-clinical audits.

Patient feedback indicated that there were no concerns regarding infection prevention and control within the practice. Patients told us they found the practice buildings clean and hygienic.

Interviews and feedback from staff informed us that they had a good understanding of infection prevention and control (IPC). However, we were informed that training regarding managing needlestick injury risk needed to be held, and this was planned for the near future. Staff told us they were aware of how to raise IPC concerns, and who to contact when they identified issues. We were told that when concerns were raised or IPC issues identified that these were addressed, and we saw evidence which supported this. The provider had recently appointed a new IPC lead who, when we spoke with them, had a good knowledge of IPC. Staff we spoke with were aware of the safe handling of clinical specimens.

We found the practice premises and equipment to be clean and hygienic, which protected people from the risk of infection. It was though noted that the structural fabric of the Westcliffe Surgery was tired and worn in areas, and needed refurbishment and redecoration in areas. For example, wall paint was damaged and peeling in areas. We saw within training records that staff had received annual infection prevention and control training. Cleaning schedules and records were in place, and the cleaners storage areas were seen to be well organised, and to carry equipment and cleaning materials to enable effective hygiene standards to be maintained.

There was an effective approach to assessing and managing the risk of infection. The provider had developed an infection prevention and control (IPC) policy which was in date, but was due for renewal in October 2024. The policy contained appropriate information which included named roles and responsibilities for staff. We saw that an IPC lead had been appointed by the provider, and that IPC checks and audits had been undertaken. IPC audits contained action plans for required improvements. We saw that issues identified at the most recent IPC audit in January 2024 had been tackled and improvements made. For example, door coving had been reaffixed. The provider had in place measures to control Legionella, and we saw records which showed regular flushing of the water system had been undertaken. A previous inspection had highlighted that the provider had not assessed the immunisation and vaccination status of staff. At the time of our visit to the practice, we found that although progress had been made to give full assurance, this had not been fully completed.

We saw no indication of any concern in this area.

Leaders and managers told us that clinicians involved patients in assessments and reviews and discussed the level and support patients needed to manage their medicines safely. We saw that medical notes and reviews supported this view, and showed evidence of patient awareness regarding their care and treatment, and any risks associated with the use of medicines. The provider told us that clinical staff met regularly, and best practice guidance was discussed at meetings. The provider told us that they ensured that staff understood their roles in respect of medicines and that required training was monitored to ensure staff remain up to date with their skills and knowledge. Staff we spoke with told us that they were kept informed of changes to guidance, and key issues such as patient safety and medicines alerts. They also confirmed that they were subject to clinical supervision, which included assessments of consultations and prescribing.

As part of our assessment a CQC GP specialist advisor (SpA) undertook several searches of patient records on the practice’s clinical records system. These searches showed that the provider had systems and processes in place which made sure that patients were recalled, attended regular monitoring as required, and that medicines were regularly reviewed. For example, of 500 patients who had been prescribed Thyroxine, we saw that 495 had been effectively monitored. The remaining 5 patients had been repeatedly called for monitoring but had not complied with these requests so far. Staff told us that they worked to try to ensure monitoring was undertaken and made frequent calls to these patients, and when required issued shorter prescription quantities to promote compliance. We saw, and heard, that the provider had a robust system in place which ensured non-medical prescribers, and new or relatively inexperienced staff had appropriate support and guidance, along with effective management and clinical supervision.

The provider had in place measures for the management of medicines. This included processes for repeat prescribing, patient reviews and monitoring, authorisations to administer medicines, and antibiotic stewardship. The provider undertook medicines improvement activity, and had undertaken regular prescribing and medicines audits. For example, the provider undertook bi-monthly audits as a failsafe to ensure patients who required monitoring checks to be undertaken had had these carried out. During our clinical searches, we saw evidence of patients being called in for overdue blood tests as a result of this clinical audit activity. Since our last inspection in 2022 the provider had made improvements to their processes for receiving, recording, and acting upon patient and medicines safety alerts. Enhanced processes had also been put in place to improve the learning, reflection, and sharing of incidents and significant events, which included those in relation to medicines. Medicines optimisation work had high level management oversight, and was reported to the Board of Directors via the provider’s Quality and Safety Group. Reported measures included high risk medicines monitoring, medicines usage, medication reviews, antibiotic prescribing, and patients safety and medicines alerts.

We saw that the provider took steps to ensure that staff prescribed medicines appropriately to optimise care outcomes. For example, antibiotic prescribing was at or below expected averages for the practice. There was a programme of clinical audits in place which supported safe prescribing and medicines optimisation. For example, we saw that a recent audit showed that the provider had adhered to guidance when prescribing an epilepsy medicine to women of childbearing age, and that decisions relating to continued prescribing of this had been fully recorded. Outcomes were closely monitored by the internal Quality and Safety Group, and reported to the Board of Directors.