What is the Quality of Safety 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

"Track record on safety The practice had a good safety record."

Positive

"• Not ensured there were systems and processes in place to assess monitor and improve the quality and safety of services through an ongoing audit programme in a range of clinical areas."

Positive

"At this inspection we found: • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events."

Positive

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

Positive

"This was because there were no systems or processes that enabled the registered person to assess monitor and improve the quality and safety of the services being provided."

Positive

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

Positive

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

Positive

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

Positive

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

Positive

"• The practice conducted safety risk assessments."

Positive

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

Positive

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

Positive

"• There were risk assessments in relation to safety issues."

Positive

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

Positive

"New safety alerts and changes in guidance were discussed at regular clinical meetings."

Positive

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

Neutral

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

Positive

"• Not ensured there were systems and processes in place to assess monitor and improve the quality and safety of services through an ongoing audit programme in a range of clinical areas."

Positive

"• Improved the arrangements for dealing with patient and safety alerts received from various sources including the Medicines and Healthcare Products Regulatory Agency MHRA."

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

"The GPs used a variety of sources to identify topics for audit including MHRA and safety alerts issues arising from meetings and personal interest."

Positive

"• Patient safety and medicines alerts were not effectively managed and the practice could not provide evidence they had reviewed all alerts in a comprehensive way."

Positive

"We were shown the most up to date matrix which showed all staff had undertaken safeguarding and fire safety training."

Positive

"Staff we spoke with were able to demonstrate their understanding and responsibilities in relation to safeguarding fire safety and information governance."

Neutral

"• Allocated protected time for staff to undertake essential training such as safeguarding fire safety and information governance."

Neutral

"• Staff had been offered protected time to undertake training in safeguarding fire safety and information governance IG."

Positive

"• Not ensured there were systems and processes in place to assess monitor and improve the quality and safety of services through an ongoing audit programme in a range of clinical areas."

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

"How the regulation was not being met: There were no systems or processes that enabled the registered person to assess monitor and improve the quality and safety of the services being provided."

Positive

"There were no systems or processes that enabled the registered person to assess monitor and mitigate the risks relating to the health safety and welfare of service users and others who may be at risk."

Positive

"The practice told us the fire drill formed part of the fire safety training for staff."

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."

Positive

"They had also allocated GP partners with individual responsibility for key areas such as patient safety alerts."

Positive

"Some staff still had not received training in fire safety and information governance."

Positive

"Overview of safety systems and process • Safeguarding policies had been reviewed and were practice specific."

Positive

"In particular fire safety awareness training had not been undertaken by a number of staff."

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."

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."

Positive

"This includes the National Institute for Health and Care Excellence NICE best practice guidelines and patient safety alerts."

Positive

"• Ensure that effective and timely care planning takes place to ensure the health safety and welfare of patients."

Positive

"Requires improvement ––– People with long term conditions The provider was rated as requires improvement for safety effective services and for being wellled."

Positive

"Requires improvement ––– Families children and young people The provider was rated as requires improvement for safety effective services and for being wellled."

Positive

"• Ensure there are systems and processes in place to assess monitor and improve the quality and safety of the services being provided by developing an ongoing audit programme in a range of clinical areas."

Positive

"• Ensured that effective and timely care planning took place to ensure the health safety and welfare of patients."

Positive

"Older people The provider was rated as requires improvement for safety effective services and for being wellled."

Positive

"Working age people including those recently retired and students The provider was rated as requires improvement for safety effective services and for being wellled."

Positive

"Requires improvement ––– People whose circumstances may make them vulnerable The provider was rated as requires improvement for safety effective services and for being wellled."

Positive

"However the practice did not have a formal internal process to ensure that information from NICE and patient safety alerts were reviewed and actioned."

Positive

"• Ensured there were systems and processes in place to assess monitor and improve the quality and safety of the services being provided by developing an ongoing audit programme in a range of clinical areas."

Positive

"• There was an open and transparent approach to safety and a system in place for reporting significant events although we found the process could be improved."

Positive

"Overview of safety systems and processes The practice had some systems processes and practices in place to keep patients safe and safeguarded from abuse which included: • There were arrangements in place to safeguard children and vulnerable adults from abuse but we found these could be improved."

Positive

"The practice had a variety of other risk assessments in place to monitor safety of the premises such as control of substances hazardous to health."

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

"People experiencing poor mental health including people with dementia The provider was rated as requires improvement for safety effective services and for being wellled."

Positive

"This included support and training for all staff on communicating with patients about notifiable safety incidents."

Positive

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

Positive

"However we found the practice had a lack of oversight for the actioning of latest guidance or best practice including patient safety alerts."

Positive

"• Not all staff we spoke with had received training that included: fire safety awareness basic life support and information governance."

Neutral

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

Positive

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

Positive

"• A new system of 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 inspection was carried out to review in detail the actions taken by the practice to improve the quality of care and to confirm that the practice was now meeting legal requirements."

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

"Action was taken as a result to improve the quality of care for example we saw evidence of practice meetings where complaints had been discussed amongst clinical staff."

Positive

"Improvements were made to the quality of care as a result of complaints and concerns."

Positive

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

Positive

"They also told us they were satisfied with the care provided by the practice and said their dignity and privacy was respected."

Positive

"Within consulting rooms we noted that curtains were provided so that patients’ privacy and dignity was maintained during examinations investigations and treatments."

Neutral

"We noted the practice had taken steps to ensure the patients privacy and dignity updated patients in the waiting room that there would be a delay and that following the incident the nursing team were asked to check and restock the emergency equipment."

Positive

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

Positive

"Overview of safety systems and processes The practice had some systems processes and practices in place to keep patients safe and safeguarded from abuse which included: • There were arrangements in place to safeguard children and vulnerable adults from abuse but we found these could be improved."

Neutral

"• The practice had systems processes and practices in place to keep patients safe and safeguarded from abuse although we found not all staff had received training appropriate to their role."

Positive

"New infection control leads had been appointed and all outstanding actions from the previous audit completed."

Positive

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

Neutral

"Both sites had a recently appointed infection control lead as the previous lead had left the practice."

Neutral

"Both had been booked on to an infection control leaders’ course in the near future."

Positive

"• Reviewed the infection control action plan and ensured all outstanding actions had been completed or had a date specified for completion within a reasonable timeframe."

Positive

"• The practice was unable to evidence they had reviewed and completed all the highlighted actions in the infection control audit."

Positive

"Basic life support infection control and information governance training had not been undertaken by all staff."

Positive

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

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."

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

"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."

Neutral

"This included the arrangements to manage infection control the completion of recruitment checks and that safeguarding training had not been completed by all staff."

Neutral

"This includes that actions from infection control audits are completed and recorded."

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

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

Neutral

"There was an infection control protocol in place and staff had received up to date training using an online training system."

Neutral

"This includes that actions from infection control audits were completed and recorded."

Positive

"• Advice on patients’ diet and smoking cessation advice was available from the health care assistant or local support groups."

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."

Neutral

"• Review the visibility of signage to inform patients of the availability of chaperones to include all treatment rooms."

Positive

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

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

"At this inspection we have focused on the warning notice findings in respect of the well led section of our report."

Positive

"Patients said they felt the practice offered an excellent service and staff were helpful caring and treated them with dignity and respect."

Positive

"Our key findings across all the areas we inspected were as follows: • 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

"They also told us they were satisfied with the care provided by the practice and said their dignity and privacy was respected."

Positive

"Results from the national GP patient survey showed patients felt they were treated with compassion dignity and respect."

Positive

"• We saw staff treated patients with kindness and respect and maintained patient and information confidentiality."

Positive

"Within consulting rooms we noted that curtains were provided so that patients’ privacy and dignity was maintained during examinations investigations and treatments."

Neutral

"We noted the practice had taken steps to ensure the patients privacy and dignity updated patients in the waiting room that there would be a delay and that following the incident the nursing team were asked to check and restock the emergency equipment."

Positive

"• The practice actively promoted equality and diversity."

Neutral

"Staff had received equality and diversity training."

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

"• Information about how to make a complaint or raise concerns was readily available and it was easy to do."

Positive

"• Structures processes and systems to support good governance and management were clearly set out understood and effective."

Positive

"Governance arrangements There were clear responsibilities roles and systems of accountability to support good governance and management."

Positive

"This was because governance arrangements had not identified a lack of response to the breaches of regulation identified in the previous inspection report findings."

Positive

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

Positive

"• The practice had reviewed its leadership and governance structure and staff felt supported by management."

Positive

"The practice failed to demonstrate that there was sufficient leadership capability and capacity to ensure governance systems were operated effectively."

Positive

"Specifically the practice had: • Reviewed the governance arrangements for all areas of practice outlined in the warning notice."

Positive

"We found the governance arrangements had improved."

Neutral

"• Staff had been offered protected time to undertake training in safeguarding fire safety and information governance IG."

Positive

"Importantly the provider must: • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care."

Positive

"The practice failed to demonstrate that there was sufficient leadership capability and capacity to ensure governance systems were operated effectively."

Positive

"Basic life support infection control and information governance training had not been undertaken by all staff."

Neutral

"• Reviewed governance processes and arrangements."

Positive

"• There was an overarching governance framework which supported the delivery of the strategy and good quality care."

Positive

"Governance arrangements The practice had an overarching governance framework which supported the delivery of the strategy and good quality care."

Positive

"Formally communicate to all staff the practice governance vision strategy and supporting business plan."

Positive

"• Communicated to all staff the practice governance vision strategy and supporting business plan."

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

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

Positive

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

Positive

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

Positive

"There was evidence of quality improvement including clinical audit."