What is the Quality of Safety at Church Lane Surgery

Positive

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

Positive

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

Positive

"• Continue to review and strengthen governance structures and recruitment issues."

Positive

"At this inspection we found that: • The practice had established clearer responsibilities roles and systems of accountability to support good governance and management."

Positive

"We previously found that: • There were not clear responsibilities roles and systems of accountability to support good governance and management."

Positive

"We also looked at the governance arrangements and the leadership of the practice."

Positive

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

Positive

"• Structures processes and systems to support good governance and management were set out however not all were understood and effective."

Positive

"The governance and management of partnerships joint working arrangements and shared services had not been embedded and therefore did not promote coordinated personcentred care."

Positive

"• There was a lack of focus on the clinical leadership and governance systems."

Positive

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

Positive

"We based our judgement of the quality of care at this service on a combination of: • what we found when we inspected • information from our ongoing monitoring of data about services and • information from the provider patients the public and other organisations."

Positive

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

Positive

"We based our judgement of the quality of care at this service on a combination of: • what we found when we inspected • information from our ongoing monitoring of data about services and • information from the provider patients the public and other organisations."

Positive

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

Positive

"We based our judgement of the quality of care at this service on a combination of: • what we found when we inspected • information from our ongoing monitoring of data about services and • information from the provider patients the public and other organisations."

Positive

"• Clinical audit did not have 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

"• The practice considered and understood the impact on the quality of care of service changes or developments."

Positive

"There was a lack systems or processes that enabled the registered person to assess monitor and improve the quality and safety of the services being provided."

Positive

"The areas where the practice should make improvements are • Continue to review historic safety alerts based on risk."

Positive

"• The safety systems in place were inadequate and did not ensure that patients and staff would be kept safe from harm."

Positive

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

Positive

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

Positive

"The practice was rated as inadequate for providing safe services because: • The safety systems in place were inadequate."

Positive

"There was no health and safety risk assessment completed on the day of inspection for the building this was completed after the inspection."

Positive

"We found there was no system in place to deal with these in a timely manner which posed a risk to patient safety as actions were not taken from these letters."

Positive

"Track record on safety The practice had a mixed track record on safety."

Positive

"However there was no health and safety risk assessment available on the day of inspection."

Positive

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

Positive

"• Leaders had established policies procedures and activities to ensure safety however could not assure themselves that they were operating as intended."

Positive

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

Positive

"• On the day of inspection the practice had not undertaken a health and safety risk assessment."

Positive

"There was a system in place to manage safety alerts."

Positive

"• The practice had not undertaken a health and safety risk assessment."

Positive

"Privacy and dignity The practice did not always respect patients’ privacy and dignity."

Positive

"We observed some aspects of care that did not manage patients’ privacy discreetly."

Neutral

"• We witnessed staff not always managing patients’ privacy discreetly."

Positive

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

Positive

"• There was not an effective system in place to safeguard service users from abuse and improper treatment."

Positive

"Kindness respect and compassion Some patients reported that staff did not always treat them with kindness respect and compassion."

Positive

"Privacy and dignity The practice did not always respect patients’ privacy and dignity."

Positive

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

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

"• Quality and sustainability were discussed however not all staff had sufficient access to information."