What is the Quality of Facilities at Sellindge Surgery

Positive

"• Where a patient’s mental capacity to consent to care or treatment was unclear the GP or practice nurse assessed the patient’s capacity and recorded the outcome of the assessment."

Positive

"During our visit we: • Spoke with a range of clinical staff including three GPs one practice nurse one health care assistant three dispensers and the practice manager."

Positive

"The practice nurse had completed mentorship training and there were plans to provide training opportunities for student nurses."

Neutral

"There is one practice nurse female and one healthcare assistant female."

Positive

"Management monitoring and improving outcomes for people The practice used the information collected for the Quality and Outcomes Framework QOF and performance against national screening programmes to monitor outcomes for patients."

Positive

"For example legionella monitoring fire safety and medicines management."

Neutral

"It is based on a combination of what we found when we inspected information from our ongoing monitoring of data about services and information given to us from the provider patients the public and other organisations."

Neutral

"• Review the system for monitoring patients receiving anticoagulation therapy from another service provider."

Positive

"• The procedures for monitoring and managing risks to the safety of patients staff and visitors were not always effective."

Positive

"• we found that the provider did not have effective procedures to manage quality improvements or governance systems relating to the monitoring of risk to patients for medicines management infection prevention and control fire safety and staff induction for nurses and training for staff."

Neutral

"For example on the day of the inspection we found that the management of controlled drugs medicines which were more liable to misuse and so need closer monitoring were not always appropriate."

Neutral

"Arrangements for controlled drugs medicines which are more liable to misuse and so need closer monitoring were not always appropriate."

Neutral

"• There were arrangements for planning and monitoring the number of staff and mix of staff needed to meet patients’ needs."

Positive

"Staff involved in dispensing activities were trained to an appropriate level and had appraisals annually."

Positive

"The areas where the provider must make improvement are: • Ensure risk assessments and management activities include all risks to patients staff and visitors."

Positive

"• Ensure internal audits such as infection prevention and control health and safety and legionella are implemented effectively and have action plans recorded."

Positive

"• The practice failed to ensure internal audits such as infection prevention and control and health and safety were effectively implemented and supported with action plans containing timeframes."

Positive

"• The practice failed to assess risks to the health and safety of service users receiving care or treatment and do all that was reasonably practicable to mitigate any such risks."

Positive

"• There was a health and safety policy available with a poster in the reception office which identified local health and safety representatives."

Neutral

"Staff told us action was taken where necessary but there were no action plans attached to the health and safety checks to confirm this."

Neutral

"This covered such topics as safeguarding infection prevention and control fire safety health and safety and confidentiality."

Positive

"• Ensure internal audits such as infection prevention and control health and safety and legionella are implemented effectively and have action plans recorded."

Positive

"• The practice failed to ensure internal audits such as infection prevention and control and health and safety were effectively implemented and supported with action plans containing timeframes."

Positive

"The practice was not able to demonstrate that all clinical and nonclinical staff were up to date with basic infection prevention and control training and the lead member of staff for infection prevention and control had not received additional training to support this role."

Positive

"For example infection prevention and control audits had failed to identify out of date sharps boxes."

Positive

"For example infection prevention and control fire safety awareness and a formal induction for the nursing team."

Positive

"For example infection prevention and control training and fire safety awareness."

Positive

"• we found that the provider did not have effective procedures to manage quality improvements or governance systems relating to the monitoring of risk to patients for medicines management infection prevention and control fire safety and staff induction for nurses and training for staff."

Neutral

"The practice had recently carried out an infection prevention and control audit."

Neutral

"This covered such topics as safeguarding infection prevention and control fire safety health and safety and confidentiality."

Positive

"• Ensure medicines management procedures for vaccines have regard to Public Health England PHE guidance and that there is an effective process for managing medicine alerts from the Medicines and Healthcare products Regulatory Agency MHRA."

Positive

"For example one of the two cycle audits examined how many patients taking a medicine for diabetes that can cause hypoglycaemia low blood sugars that can result in confusion and loss of consciousness had received equipment to test their blood sugars and been given advise about driving."

Positive

"However the practice could not demonstrate that they had an effective system for managing medicine alerts from the Medicines and Healthcare products Regulatory Agency MHRA."

Positive

"For example no action had been taken regarding alerts for nicorandil a medicine used for treating heart conditions and spironolactone a medicine used to treat high blood pressure."

Positive

"However we noted that the practice did not have chlorphenamine a medicine for used for in anaphylaxis or hydrocortisone for injections used for acute severe asthma."

Positive

"• The practice could not demonstrate that they had an effective system for managing all medicine alerts from the Medicines and Healthcare products Regulatory Agency MHRA."

Neutral

"• Staff told us that they received emails about medicine alerts and we saw that some action had been taken."

Neutral

"Written guidance on what action should be taken in the event that medicine storage temperatures went outside of acceptable limits was available to guide staff."

Neutral

"For example taking action for all medicine alerts from the Medicines and Healthcare products Regulatory Agency MHRA."

Neutral

"For example: • Patients receiving end of life care carers those at risk of developing a longterm condition and those requiring advice on their diet smoking and alcohol cessation."

Positive

"For example staff that reviewed patients with longterm conditions had received training in areas such as wound care and respiratory conditions."

Positive

"• A programme of continuous clinical audit was used to monitor quality and to make improvements."

Positive

"This included ongoing support onetoone meetings coaching and mentoring clinical supervision and facilitation and support for revalidating GPs."