What is the Quality of Facilities at Sutherland Lodge Surgery

Positive

"• Staff encouraged and supported patients to be involved in monitoring and managing their own health for example through social prescribing schemes."

Positive

"• Arrangements were in place for planning and monitoring the number and mix of staff needed to meet patients’ needs including planning for holidays sickness busy periods and epidemics."

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 was a process for the management of medicines including high risk medicines for example warfarin methotrexate and lithium with appropriate monitoring and clinical review prior to prescribing."

Neutral

"For example specific INR monitoring clinics COPD asthma and diabetes clinics."

Positive

"• The practice had implemented a programme of quality monitoring activity and was starting to review the effectiveness and appropriateness of the care provided."

Positive

"• Arrangements were in place for planning and monitoring the number and mix of staff needed to meet patients’ needs including planning for holidays sickness busy periods and epidemics."

Positive

"• The practice was involved in quality monitoring activities such as clinical audit."

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

"• Systems relating to monitoring and analysis of test results and recall of patients were in place."

Positive

"There was a lack of review and monitoring of patients and performance generally."

Positive

"• Patients on medicine that required monitoring were identified and sent appropriate test requests to ensure they were not at risk of developing side effects."

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

"These letters included changes in medicines requests to refer to different specialists and blood monitoring requirements."

Neutral

"Staff had been trained and they were monitoring the process."

Neutral

"• A policy had been developed and a pharmacist was checking on all patients that required monitoring while on highrisk medicine."

Positive

"The results of monitoring were not used effectively to improve quality."

Positive

"• We found that there was a lack of oversight at the practice from the corporate leaders of the practice and systems and processes in place were not being followed and there was a lack of review and monitoring taking place."

Positive

"• There was no effective approach to monitoring reviewing or providing evidence of progress against delivery of the strategy or plans."

Positive

"• Medicines and associated equipment were not always in date or stored at the correct temperature and nursing staff tasked with monitoring did not take action when temperatures were above recommended levels."

Positive

"Monitoring care and treatment There was limited or no monitoring of the outcomes of care and treatment."

Positive

"• There was no proactive monitoring of patients considered to be at risk of safeguarding concerns."

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

"This is to include repeat prescribing and monitoring of highrisk medicines."

Neutral

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

Neutral

"There was limited measurement and monitoring of safety performance."

Neutral

"One example seen requested blood monitoring to be performed and this had not been completed."

Neutral

"• There was no overall understanding of the quality markers at the practice with no routine audits or monitoring of patient data."

Positive

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

Positive

"• The practice was involved in quality monitoring activities such as clinical audit."

Positive

"• Practice leaders had established policies procedures and activities to ensure safety."

Positive

"The provider did not do all that was practicable to assess monitor and improve the quality and safety of the services provided in the carrying on of the regulated activities including the quality of the experience of the service users in receiving those services."

Positive

"• The practice’s uptake for breast and bowel cancer screening was below local and the national averages."

Positive

"The GP and practice nurse also accommodated home visits for those who had difficulties getting to the practice due to limited local public transport availability."

Neutral

"• The clinical team comprises of three salaried GPs two female advance nurse practitioners and a range of clinical locums."

Positive

"The GP and practice nurse also accommodated home visits for those who had difficulties getting to the practice due to limited local public transport availability."

Positive

"The GP and practice nurse also accommodated home visits for those who had difficulties getting to the practice due to limited local public transport availability."

Neutral

"• The practice ensured that end of life care was delivered in a coordinated way which took into account the needs of different patients including those who may be vulnerable because of their circumstances."

Positive

"Notes we viewed did not have any documentations identifying any conversations about end of life care in the last phase of life was part of planning their treatment and care in a way which responds to their individual preferences."

Neutral

"This included one to one meetings appraisals clinical supervision and revalidation."

Positive

"• The practice had completed most actions required from environmental risk assessment however we found that the health and safety risk assessment was difficult to follow and did not document actions that had been completed."

Neutral

"The practice had completed a health and safety assessment but it was unclear whether the actions had been completed."

Positive

"Staff responsible for the management of risks and health and safety were not aware of the scope of these responsibilities."

Neutral

"The areas where the provider must make improvements are: • Ensure there are systems to assess monitor manage and mitigate risks to the health and safety of patients who use services."

Positive

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

Positive

"For example the practice had carried out a number of medicine audits which ensured patients were not at risk."

Positive

"The second was an over prescribing issue with a medicine that was known to be open to misuse abuse and dependence."

Positive

"• Procedures in relation to patient medicine alerts had been reviewed and appropriate action taken to ensure patients were safe."

Positive

"• Action to ensure storage of medicine was safe had been discussed and all staff were aware of their responsibilities to report any recording outside the recommended guidance."

Positive

"This would include what the medicine was for how to use it possible unwanted effects and how to report them also what the expected duration of treatment would be."

Positive

"There was no system to ensure patient safety and medicine alerts were acted on."

Positive

"• Patients on medicine that required monitoring were identified and sent appropriate test requests to ensure they were not at risk of developing side effects."

Positive

"We reviewed their notes and saw the medicine had stopped being prescribed."

Neutral

"The first involved a child that was prescribed medicine not licenced for children."

Neutral

"• Medicine advice leaflets had been developed and staff had been made aware to discuss new medicine with patients."

Neutral

"There was a programme that identified four medicine audits over the year."

Positive

"The second was an over prescribing issue with a medicine that was known to be open to misuse abuse and dependence."

Positive

"This would include what the medicine was for how to use it possible unwanted effects and how to report them and how long they may be on that medicine."

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

"There was a lack of clinical oversite to ensure information received regarding new diagnosis and medicine changes were not completed in a timely way."

Neutral

"The first involved a child that was prescribed medicine not licenced for children."

Positive

"• We heard a receptionist talking to a mother stating there were no available appointments for her child to be seen on the same day."

Neutral

"• On the day of the inspection a receptionist told the inspector that requests for longer appointments were not always available as there was often only one appointment slot available."

Neutral

"The issue was discussed at the clinical governance meeting where five prescribing clinicians attended."

Positive

"• Appropriate checks of locum GPs in relation to conduct in previous roles disclosure and barring service DBS checks and medical indemnity insurance were inconsistent."

Positive

"There was no schedule for cleaning them."

Positive

"There were no cleaning schedules for the extractor fans."

Neutral

"Monitor and schedule cleaning of areas where debris collects."

Neutral

"• An infection control lead had been appointed and cleaning schedules have been revised."