What is the Quality of Safety at Thornbury Medical Practice

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

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

Positive

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

Positive

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

Positive

"• Curtains were provided in consulting rooms to maintain patients’ privacy and dignity during examinations investigations and treatments."

Positive

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

Positive

"• Curtains were provided in consulting rooms to maintain patients’ privacy and dignity during examinations investigations and treatments."

Positive

"• The practice had established systems and processes which had improved the safety and quality of the service provided."

Positive

"Track record on safety The practice had improved their approach to safety."

Positive

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

Positive

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

Positive

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

Positive

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

Positive

"• There was an effective process to identify understand monitor and address current and future risks including risks to patient safety of which the practice manager had oversight."

Positive

"Practice leaders had oversight of national and local safety alerts incidents and complaints."

Positive

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

Positive

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

Positive

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

Positive

"Training undertaken included basic life support fire safety Infection Prevention and Control IPC and safeguarding training."

Positive

"• The practice had a variety of other risk assessments to monitor safety of the premises such as control of substances hazardous to health and infection control and legionella Legionella is a bacterium which can contaminate water systems in buildings."

Positive

"The practice had systems for being aware of notifiable safety incidents and sharing the information with staff and ensuring appropriate action was taken."

Positive

"• We saw evidence that action was taken to improve safety in the practice."

Positive

"The arrangements for managing medicines including emergency medicines and vaccines in the practice minimised risks to patient safety including obtaining prescribing recording handling storing security and disposal."

Positive

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

Positive

"• There was a basic health and safety policy available."

Positive

"• Staff received training that included: safeguarding fire safety awareness basic life support and information governance."

Positive

"How the regulation was not being met: The registered person had systems and processes in place that operated ineffectively in that they failed to enable the registered person to assess monitor and improve the quality and safety of the services being provided."

Neutral

"Overview of safety systems and processes The practice had systems processes and practices in place to minimise risks to patient safety."

Neutral

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

Positive

"The practice manager told us when there are unintended or unexpected safety incidents people receive appropriate support truthful information a verbal and written apology and are told about any actions to improve processes to prevent the same thing happening again."

Positive

"Our key findings across all the areas we inspected were as follows: • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events."

Positive

"• Lessons were shared to make sure action was taken to improve safety in the practice."

Positive

"• When there were unintended or unexpected safety incidents people receive reasonable support and actions were instigated to improve processes to prevent the same thing happening again."

Positive

"Lessons were shared to make sure action was taken to improve safety in the practice."

Positive

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

Positive

"We reviewed safety records incident reports national patient safety alerts and minutes of meetings where these were discussed."

Positive

"There was a health and safety policy available with information in the reception area."

Positive

"The practice had systems in place for knowing about notifiable safety incidents."

Positive

"When there were unexpected or unintended safety incidents: • The practice gives affected people reasonable support truthful information and a verbal or written apology."

Neutral

"• The practice had an induction programme for newly appointed nonclinical members of staff that covered such topics as safeguarding infection prevention and control fire safety health and safety and confidentiality."

Positive

"• Staff took steps including working with other agencies 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

"• Staff interviewed knew how to recognise signs of abuse in children young people and adults whose circumstances may make them vulnerable."

Positive

"• Staff were able to recognise the signs of abuse in older patients and knew how to escalate any concerns."

Positive

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

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

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

Positive

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

Positive

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

Positive

"• Staff took steps including working with other agencies to protect patients from abuse neglect harassment discrimination and breaches of their dignity and respect."

Positive

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

Positive

"• However the majority of patients we spoke with on the day of inspection and patient comment cards reflected that there had been positive changes within the practice and patients were treated with dignity respect and kindness."

Positive

"They 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 the majority of 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

"• Curtains were provided in consulting rooms to maintain patients’ privacy and dignity during examinations investigations and treatments."

Positive

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

Positive

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

"• The majority of patients said they were treated with compassion dignity and respect."

Positive

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

Positive

"• Curtains were provided in consulting rooms to maintain patients’ privacy and dignity during examinations investigations and treatments."

Positive

"• The practice actively promoted equality and diversity."

Positive

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

Positive

"• The complaint policy and procedures were updated after our inspection to ensure that they were in line with recognised guidance."

Neutral

"We saw an example of where a multidisciplinary team meeting was held following a complaint with a view to formulating a plan to support the patient."

Positive

"• There were positive relationships between staff and managers Governance arrangements There were clear responsibilities roles and systems of accountability to support good governance and management."

Positive

"• Structures processes and systems to support good governance and management 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."

Positive

"Areas for improvement Action the service MUST take to improve • The provider must establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care."

Positive

"Governance arrangements The practice had a governance framework to support the delivery of the strategy and good quality care."

Positive

"The areas where the provider must make improvements are: • The provider must establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care."

Neutral

"• The practice had policies and procedures to govern activity and held regular governance meetings."

Positive

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

Neutral

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

Neutral

"• Staff received training that included: safeguarding fire procedures basic life support and information governance awareness."

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 was actively involved in quality improvement activity."

Positive

"There was evidence of quality improvement including clinical audit: • We reviewed two clinical audits which had been undertaken in the last two years."

Positive

"• The practice had a variety of other risk assessments to monitor safety of the premises such as control of substances hazardous to health and infection control and legionella Legionella is a bacterium which can contaminate water systems in buildings."

Positive

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

Positive

"The practice nurse was the infection control clinical lead who liaised with the local infection prevention teams to keep up to date with best practice."

Neutral

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

Neutral

"Annual infection control and cleaning audits were undertaken and we saw evidence that action was taken to address any improvements identified as a result."