What is the Quality of Safety at Alderwood Medical Practice

Neutral

"For example: • Patients receiving end of life care carers those at risk of developing a longterm condition those requiring advice on their diet and smoking cessation."

Positive

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

Positive

"Patients told us staff were helpful caring treated them with dignity and respect and they felt listened to."

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

"The areas where the provider must make improvements as they are in breach of regulations are: • Ensure care and treatment is provided in a consistent safe way to patients • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care."

Positive

"However arrangements for clinical leadership and overall governance structures required further development and changes fully embedded to improve patient care."

Positive

"• Develop and improve governance structures."

Positive

"• The practice had systems and processes in place that mostly supported an overarching governance framework that improved the quality and safety of their service."

Positive

"The practice did have embedded systems and processes in place to support an overarching governance framework that improved the quality and safety of their service."

Positive

"Most governance and audit arrangements were effective but we found some areas that required ongoing review."

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 inspection was carried out to review in detail the actions taken by the practice to improve the quality of care and to confirm whether the practice had implemented the required improvements."

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

"• There was not an effective system in place for receiving and acting on safety alerts."

Positive

"• Not all staff had received uptodate essential training to include certified fire safety and safeguarding children."

Positive

"• Not all staff had received uptodate essential training to include fire safety and safeguarding children."

Positive

"• The process for documenting the action taken in response to external alerts that may affect patient safety had improved."

Positive

"• Document actions taken in response to external medicine safety alerts and ensure they are fully documented in patients’ records."

Positive

"• Health and safety arrangements to minimise risk to patients and staff did not cover all areas of the practice and there was no appointed lead."

Positive

"• Although a designated health and safety lead had been appointed the name of the lead was not detailed on the health and safety poster displayed but this was rectified at the time of the inspection."

Positive

"• Health and safety policies and protocols to identify assess and minimise risk to patients and staff had been developed but required further improvement."

Positive

"• The process for documenting the action taken in response to external alerts that may affect patient safety was not effective."

Positive

"We saw a health and safety policy was in place but this was not dated."

Positive

"Lessons learned and improvements made • The practice had reviewed their system for acting on alerts that may affect patient safety for example from the Medicines and Healthcare products Regulatory Agency MHRA."

Positive

"A safety alerts folder and written protocol had been developed in addition to a safety alert templates used when circulating incoming external alerts."

Positive

"In particular: The registered persons had not done all that was reasonably practicable to mitigate risks to the health and safety of service users receiving care and treatment."

Neutral

"Track record on safety • Since the last inspection the practice had reviewed and developed a range of risk assessments to monitor the safety of the premises."

Positive

"• The practice had systems and processes in place that mostly supported an overarching governance framework that improved the quality and safety of their service."

Positive

"Overview of safety systems and processes The practice had systems processes and practices in place to keep patients safe and safeguarded from the risk of abuse which included: • All staff knew their individual responsibility for safeguarding children and vulnerable adults from the increased risk of harm."

Positive

"The practice did have embedded systems and processes in place to support an overarching governance framework that improved the quality and safety of their service."

Positive

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

Positive

"The practice had systems in place for notifiable safety incidents and ensured this information was shared with staff and appropriate action was taken."

Positive

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

Positive

"• Further develop the health and safety policies and protocols to identify assess and minimise risk to patients and staff using risk assessments and a review of the process for responding to alerts."

Positive

"Further develop the health and safety policies and protocols to identify assess and minimise risk to patients and staff using risk assessments and a review of the process for responding to alerts."

Positive

"The practice’s process to act on alerts that may affect patient safety for example from the Medicines and Healthcare products Regulatory Agency MHRA was not always fully effective."

Positive

"There was a safety net approach whereby the ANP reviewed all discharges Are services effective?"

Positive

"The health and safety poster was displayed but there was no appointed health and safety lead."

Positive

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

Positive

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

Neutral

"• Health and safety arrangements did not cover all areas of the practice and there was no appointed lead."

Neutral

"• The development of health and safety procedures to ensure risks to staff and patients were regularly assessed."

Positive

"However the vulnerable adults safeguarding policy did not reflect updated categories or definitions of the types of abuse such as modern slavery or female genital mutilation FGM."

Positive

"Overview of safety systems and processes The practice had systems processes and practices in place to keep patients safe and safeguarded from the risk of abuse which included: • All staff knew their individual responsibility for safeguarding children and vulnerable adults from the increased risk of harm."

Positive

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

Positive

"• A sign at reception advised patients to ask if they wanted to discuss sensitive issues or appeared distressed they could offer them a private room to discuss their needs."

Positive

"These discussions resulted in a change in the privacy statement used by the care agency and the practice reviewed its own policy and produced an internal poster that detailed and differentiated the disclosure of patient information to NHS organisations and third parties."

Positive

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

Positive

"For example a privacy board was placed in reception to improve patient confidentiality."

Neutral

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

Positive

"One complaint was from a patient who felt that delayed referrals had resulted in a lengthy period of treatment and recovery."

Positive

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