What is the Quality of Facilities at Sidley Medical Practice

Positive

"In particular: • The provider had failed to identify the risks associated with insufficient processes and records for identifying acting on reviewing and monitoring patient and medicine safety alerts issued from the Medicine and Healthcare products Regulatory Agency."

Positive

"In particular there was minimal evidence of quality improvement and monitoring through clinical audit."

Positive

"• Staff encouraged and supported patients to be involved in monitoring and managing their health."

Positive

"Practice leaders had oversight of a comprehensive system for monitoring discussing and actioning MHRA alerts incidents and complaints."

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

"• There were arrangements for planning and monitoring the number and mix of staff needed."

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."

Positive

"In particular: • The provider had failed to identify the risks associated with insufficient processes and records for identifying acting on reviewing and monitoring patient and medicine safety alerts issued from the Medicine and Healthcare products Regulatory Agency."

Positive

"In particular: • There was minimal evidence of quality improvement and monitoring through clinical audit."

Positive

"Management monitoring and improving outcomes for people • The practice showed us four clinical audits which had been undertaken since the last inspection."

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."

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

"The areas where the provider must make improvements are: • Ensure that there are clear processes for reporting recording acting on and monitoring significant events incidents and near misses that are understood by all staff."

Positive

"The system also enabled better monitoring of call numbers for determining staff resources."

Positive

"• Ensured that there were clear processes for reporting recording acting on and monitoring significant events incidents and near misses that are understood by all staff."

Positive

"• There were procedures in place for monitoring and managing risks to patient and staff safety."

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

"• Arrangements were in place for planning and monitoring the number of staff and mix of staff needed to meet patients’ needs."

Positive

"An equality and diversity policy was not available on the day of inspection and the health and safety policy was still to be added to the dashboard although the practice was able to reference an older one on their intranet system."

Positive

"The practice were able to provide the most up to date equality and diversity and health and safety policies within two days of the inspection."

Positive

"• Ensured the risks to the health and safety of patients and staff had been assessed and mitigated where reasonably possible by conducting and recording fire drills at least annually to include whole practice evacuation."

Positive

"• Ensure the risks to the health and safety of patients and staff has been assessed and mitigated where reasonably possible by conducting and recording fire drills at least annually to include whole practice evacuation."

Positive

"There was a health and safety policy available with a poster in the staff area which identified local health and safety representatives."

Neutral

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

Positive

"In addition there are nine members of the nursing team; six practice nurses one male five female one of whom is training to be an advanced nurse practitioner an associate practitioner two health care assistants all female and a clinical pharmacist."

Positive

"One of the practice nurses was training to become an advanced nurse practitioner whilst working in the practice."

Neutral

"How we carried out this inspection During our visit we: • Spoke with a range of staff including three GPs the interim practice manager a practice nurse an associate practitioner personnel manager and four administrationreception staff."

Positive

"The role was partly shared with the deputy nurse manager and deputy practice manager and we found that it was not always clear who had responsibility for all of the aspects of this role."

Positive

"The infection control nurse had liaised with the local clinical commissioning group infection prevention lead in order to obtain up to date policies and best practice."

Positive

"We saw evidence that the infection control nurse had made a number of improvements since taking on the role such as developing a tip sheet to include advice for waste segregation and sharps injuries."

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

"Additionally a practice nurse was creating standard templates for the clinical computer system to be used nationally which included for reviewing care plans for patients with diabetes asthma and chronic obstructive pulmonary disease."

Neutral

"A practice nurse had very recently become the infection control clinical lead and certified training had not yet been undertaken."

Neutral

"A nurse appointment was available within two weeks."

Positive

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

Neutral

"• There was a television screen in the waiting room with messages in large print and information could be printed in large print by the reception staff."

Neutral

"• A notice on the television information screen in the waiting room advised patients that chaperones were available if required but we noted that signs were not visible in the treatment rooms."

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

"This allowed them to carry out dressings and wound care in addition to other roles."

Positive

"• A new system of clinical audit had a positive impact on quality of care and outcomes for patients."

Positive

"• We found a lack of ongoing clinical audit programme to show that continuous improvements had been made."

Positive

"This included an induction process onetoone meetings appraisals coaching and mentoring clinical supervision and support for revalidation."

Positive

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

Positive

"• The infection control audit action plan was incomplete and records of cleaning of medical equipment were not kept."

Neutral

"Completed actions had not been documented including records of cleaning of medical equipment."

Neutral

"Cleaning records did not include items of medical equipment and the practice could not demonstrate regular cleaning of medical equipment took place."

Neutral

"Completed actions had not been documented including records of cleaning of medical equipment."

Positive

"• The infection control audit action plan was incomplete and records of cleaning of medical equipment were not kept."

Neutral

"For example clinical equipment cleaning records were not kept although the practice told us regular cleaning took place."

Neutral

"• Cleaning of fabric curtains in treatment rooms had been maintained every six months and the practice had decided to replace these with disposable curtains when the next date for cleaning was due."

Neutral

"Completed actions had not been documented including records of cleaning of medical equipment."

Positive

"This included significant event processes the arrangements to manage infection control the recording and completion of some aspects of cleaning the completion of patient care plans the recruitment checks carried out and the use of patient group directions and patient specific directions was not in line with legislation."

Positive

"We also were told about appropriate cleaning carried out for the clinical equipment but we were not shown evidence this was recorded with the exception of one piece of equipment used for ear irrigation."

Positive

"Ensure that the cleaning of medical equipment and fabric curtains is undertaken recorded and monitored."

Neutral

"This included the arrangements to manage infection control the recording and completion of some aspects of cleaning the recruitment checks carried out and the use of patient group directions and patient specific directions was not in line with legislation."

Neutral

"We reviewed the practice cleaning schedule and task list however we noted the cleaning of fabric curtains used in clinical rooms was not included."

Neutral

"Ensured that the cleaning of medical equipment and fabric curtains is undertaken recorded and monitored."

Positive

"In particular: • The provider had failed to identify the risks associated with insufficient processes and records for identifying acting on reviewing and monitoring patient and medicine safety alerts issued from the Medicine and Healthcare products Regulatory Agency."

Positive

"For example a patient had been on a medicine for some years and had been suffering from persistent headaches."

Positive

"The practice learned from external safety events as well as patient and medicine safety alerts."

Positive

"Exception reporting is the removal of patients from QOF calculations where for example the patients decline or do not respond to invitations to attend a review of their condition or when a medicine is not appropriate."

Positive

"• Not established formal pathways and processes to ensure patient safety and medicine alerts were received reviewed actioned and recorded."

Neutral

"When she saw a new GP they realised that there were contraindications to the use of the medicine in that patient and that the headaches may be a side effect."

Positive

"• The arrangements for receiving and acting on patient safety and medicine alerts received from the Medicines and Healthcare products Regulatory Agency MHRA had improved."

Positive

"• Not established formal pathways and processes to ensure patient safety and medicine alerts were received reviewed actioned and recorded."

Positive

"In particular: • The provider had failed to identify the risks associated with insufficient processes and records for identifying acting on reviewing and monitoring patient and medicine safety alerts issued from the Medicine and Healthcare products Regulatory Agency."

Positive

"Our key findings were as follows: • There was no formalised process for reviewing assessing risk and taking action for patient and medicine safety alerts."

Positive

"• There was no formalised process for reviewing assessing risk and taking action for patient and medicine safety alerts."

Positive

"• Not ensured formal pathways and processes to ensure patient safety and medicine alerts were received reviewed actioned and recorded."

Neutral

"The arrangements for reviewing and implementing action for patient and medicine safety alerts staff awareness of significant event reporting and processes infection control audit documentation staff recruitment files staff training records appraisals and clinical audits were ineffective."

Neutral

"• We reviewed medicine and other safety alerts from the Medicines and Health Products Regulatory Agency MHRA and found there was an insufficient process for ensuring all were reviewed documented and actioned."

Neutral

"The practice was Accredited Paperlight with all pathology imaging results letters medicine and nonmedicine tasks being electronic."

Neutral

"Their background check with the disclosure and barring service was from their previous employer and was over three years old."

Positive

"• There was a selfservice blood pressure machine lift disabled facilities baby changing facilities a hearing loop and translation services available."

Neutral

"This included a lift portable hearing loop disabled facilities and baby changing facilities."