What is the Quality of Safety at Albion Medical Practice

Positive

"Good As part of our inspection process we also look at the quality of care for specific population groups."

Positive

"· Clinical audit had a positive impact on quality of care and outcomes for patients."

Positive

"This report describes our judgement of the quality of care at this service."

Positive

"This report describes our judgement of the quality of care at this service."

Positive

"This report describes our judgement of the quality of care at this service."

Positive

"Privacy and dignity The practice respected and promoted patients’ privacy and dignity."

Positive

"Curtains were provided in consulting rooms and treatment rooms so that privacy and dignity was maintained during examinations."

Neutral

"We saw that consultations and treatments were carried out in the privacy of a consulting room and conversations could not be heard through closed doors."

Positive

"All the patients spoken with said their privacy was maintained they were involved in decision making and were always asked for their consent or permission before any invasive treatment or examinations took place."

Positive

"Staff told us that if necessary they would speak to any patient in a quiet room so that their privacy could be respected."

Positive

"The practice learned and in the main shared lessons and took action to improve safety in the practice."

Positive

"• All staff received uptodate safeguarding and safety training appropriate to their role."

Positive

"Some patients medication continued to be prescribed despite the safety alert and there was no record of discussion about the risks having taken place with patients."

Positive

"• There was a strong emphasis on the safety and wellbeing of all staff."

Positive

"Track record on safety • There were comprehensive risk assessments in relation to safety issues."

Positive

"• Practice leaders had established proper policies procedures and activities to ensure safety and assured themselves that they were operating as intended."

Positive

"At this inspection we found: • The practice had some systems in place to manage risk so that safety incidents were less likely to happen."

Positive

"• The practice conducted safety risk assessments."

Positive

"It had a suite of safety policies which were regularly reviewed and communicated to staff."

Positive

"Staff received safety information for the practice as part of their induction and refresher training."

Positive

"• There was a system for receiving and acting on safety alerts."

Positive

"• There was an effective process to identify understand monitor and address current and future risks however systems to monitor risks to patient safety needed to be more robust for example MHRA alerts and monitoring safeguarding."

Neutral

"This helped it to understand risks and gave a clear accurate and current picture that led to safety improvements."

Positive

"All staff were fully trained on the system and commented positively about the system’s safety and ease of use."

Positive

"Learning and improvement from safety incidents There were records of six significant events over the previous twelve months which showed details of the incidents actions taken and lessons learned."

Positive

"Health and safety information was displayed for staff to see and the practice manager was responsible for health and safety within the practice."

Positive

"• Information about safety was recorded monitored appropriately reviewed and addressed."

Positive

"Information about safety was recorded monitored appropriately reviewed and addressed."

Positive

"National patient safety alerts came directly to the practice manager who passed them on to the appropriate members of staff."

Positive

"Monitoring safety and responding to risk The practice had systems processes and policies in place to manage and monitor risks to patients staff and visitors to the practice."

Positive

"We reviewed safety records completed over the previous few years and incident reports and minutes of meetings where these had been discussed."

Positive

"Reliable safety systems and processes including safeguarding There were systems in place to review risks to vulnerable children young people and adults."

Positive

"The practice also had a health and safety policy."

Positive

"There were robust systems in place to help ensure patient safety through learning from incidents and the safe management of medicines."

Positive

"Monitoring safety and responding to risk There were systems in place to identify and monitor risks to patients."

Positive

"However we found that improvements were required to some systems to ensure that patient safety was not compromised by any breakdown in communication about safety."

Positive

"Our findings Safe patient care We saw mechanisms in place to report and record safety incidents and we spoke with staff who were able to describe what they would do in the event of any issue or emergency."

Positive

"This could have compromised patient safety which we fed back to one of the doctors and the practice manager at the inspection."

Positive

"We found that improvements were required to ensure that all staff received and understood information that was disseminated and patient safety was not compromised because communication had broken down."

Positive

"This would have an adverse effect on patient safety in an emergency situation."

Positive

"Staff took steps to protect patients from abuse neglect harassment discrimination and breaches of their dignity and respect."

Positive

"Staff knew how to recognise signs of abuse in vulnerable adults and children."

Positive

"All had been trained in the safeguarding of vulnerable adults and all were able to describe what they would do if they suspected abuse or if an emergency incident arose."

Positive

"Staff were able to describe how they would deal with any cases of abuse or emergency and were trained on how to keep people safe."

Positive

"Safeguarding All staff spoken with were able to describe the different forms of abuse and knew what to do in the event of any Are services safe?"

Positive

"Health promotion and prevention The assistant practitioner at the practice held clinics to promote healthy living and provided advice on smoking cessation diet and alcohol intake."

Positive

"Kindness respect and compassion Staff treated patients with kindness respect and compassion."

Positive

"• Staff involved and treated patients with compassion kindness dignity and respect."

Positive

"• All of the seven patients we spoke with on the day of the inspection were positive about the care and treatment they had received and told us they were treated with dignity and respect."

Positive

"Privacy and dignity The practice respected and promoted patients’ privacy and dignity."

Positive

"• Staff recognised the importance of patients’ dignity and respect."

Positive

"Staff took steps to protect patients from abuse neglect harassment discrimination and breaches of their dignity and respect."

Positive

"• Staff were clear on their roles and accountabilities including in respect of safeguarding and infection prevention and control."

Positive

"Patientcarer support to cope emotionally with care and treatment One patient we spoke with went into great detail telling us about the support received following the death of their partner and further emotional support provided to them and their family when needed at another time."

Positive

"• Patients said they were treated with compassion dignity and respect and they were involved in their care and decisions about their treatment."

Positive

"Patients said they were treated with compassion dignity and respect and they were involved in decisions about their care and treatment."

Positive

"Patients spoke highly of all the staff and in particular praised the receptionists for their kindness and patience."

Positive

"We saw that staff treated patients with kindness empathy and respect and maintained confidentiality."

Positive

"Curtains were provided in consulting rooms and treatment rooms so that privacy and dignity was maintained during examinations."

Positive

"There was an open and honest culture and clinical administrative and reception staff all encompassed the key concepts of compassion dignity respect and equality."

Positive

"Our findings Respect dignity compassion and empathy The provider’s induction and training programmes emphasised the need for a patient centred approach to care."

Positive

"Staff understood the values and ethos of the practice which included key concepts such as compassion dignity respect and equality."

Positive

"We saw that staff spoke to all patients with dignity and respect and we observed staff being helpful and patient."

Positive

"They said that all staff at the practice treated them with dignity respect and understanding."

Positive

"Patients told us they were listened to treated with respect and were involved in decisions about their care needs."

Positive

"Patients spoken with told us they were listened to treated with respect and were involved in decisions about their care needs."

Neutral

"We spoke with one person who had been bereaved and they said they had received considerable emotional support from the clinicians and administration staff at the practice."

Positive

"• The practice actively promoted equality and diversity."

Neutral

"Staff had received equality and diversity training."

Positive

"Tackling inequity and promoting equality The practice did not have a large diversity in its population but had recognised the needs of different groups in the planning of its services."

Neutral

"Staff had not received equality and diversity training but reception and administration staff had undertaken “how to deal with patients” training which covered different scenarios they might face."

Positive

"• Information about how to make a complaint or raise concerns was available."

Positive

"• The complaint policy and procedures were in line with recognised guidance."

Positive

"There was clear information in the reception area and on the practice website about how to make a complaint and how that complaint could be escalated to the Ombudsman if the patient was dissatisfied with the response."

Positive

"We saw that a complaint was made about a lack of GP cover which impacted on home visits and noted a change in practice so that there was a specific doctor to cover home visits on a daily basis."

Positive

"None of the patients we spoke with had needed to make a complaint at any time."

Positive

"We saw that one complaint had been escalated and was being dealt with by the Parliamentary and Health Service Ombudsman."

Positive

"• Structures processes and systems in the main supported good governance and management roles were clearly set out understood and effective."

Positive

"• The governance and management of partnerships joint working arrangements and shared services promoted interactive and coordinated personcentred care."

Neutral

"The practice had a number of policies and procedures to govern activity and held regular governance meetings."

Positive

"• Quality and sustainability were discussed in relevant meetings where all staff had sufficient access to information."

Positive

"Monitoring care and treatment The practice had a comprehensive programme of quality improvement activity and routinely reviewed the effectiveness and appropriateness of the care provided."

Positive

"• The practice had a quality improvement programme in place to identify patients with long term conditions enabling them to provide appropriate care and treatment and support patients to lead healthier lifestyles."

Positive

"Monitoring and reviewing QOF and prescribing data as part of clinical meetings and using quality evaluation and quality improvement tools to monitor outcomes for patients."

Positive

"• The practice monitored progress against delivery of the strategy and had a quality improvement programme in place."

Positive

"For example: • The continued quality improvement programme which engaged staff at all levels • Staff knew about improvement methods and had the skills to use them."

Positive

"The practice had a realistic strategy and supporting business plans to achieve priorities as well as an annual quality improvement plan."

Positive

"• The practice was actively involved in quality improvement activity."

Positive

"As a result they had a quality improvement plan in place to identify at risk patients and provide education care and treatment to those patients identified as having a long term condition."

Positive

"The practice had a team responsible for the prevention and control of infection which included one of the GPs the assistant practitioner and the practice manager."

Positive

"Cleanliness and infection control We observed the premises to be clean and tidy."

Neutral

"Staff received induction training about infection control specific to their role and received annual updates."

Positive

"The assistant nurse practitioner was the infection control lead and was aware of requirements such as sharps disposal and what to do in the event of a needle stick injury."

Neutral

"Cleanliness and infection control We looked at all areas of the practice including clinic rooms and doctors surgeries."

Neutral

"We reviewed the infection control policy and staff spoken with told us they knew how to access this policy."

Positive

"These included a medication review which improved a patient’s whole quality of life and an opportunistic “message in a bottle” plan for an elderly patient worried about their pet if they had to go into hospital."

Positive

"The practice undertook quality monitoring audits such as environmental and maintenance checks to ensure that the service provided was satisfactory and effective."