What is the Quality of Safety at Sutherland Lodge Surgery

Positive

"• The practice sign post patients to local services when appropriate."

Positive

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

Positive

"• Staff involved and treated patients with compassion kindness dignity and respect."

Positive

"• The practices GP patient survey results were in line with local and national averages for questions relating to kindness respect and compassion."

Positive

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

Positive

"• Staff were clear on their roles and accountabilities including in respect of safeguarding and infection prevention and control."

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 discrimination and breaches of their dignity and respect."

Positive

"Staff were clear on their roles and accountabilities including in respect of safeguarding."

Positive

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

Positive

"Kindness respect and compassion Feedback form patients and comment cards told us there were times when people did not feel well supported or cared for."

Positive

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

Positive

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

Positive

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

Positive

"Some audits had been initiated in respect of prescribing however there was limited evidence that they had resulted in quality improvement."

Positive

"• Clinical audit had a positive impact on quality of care and outcomes for patients."

Positive

"This recognises the significant improvements made to the quality of care provided by this service."

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

"• Clinical audit was beginning to 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 was aware of the impact on the quality of care of service changes or developments."

Positive

"It used this information to improve the quality of care and prevent similar complaints occurring."

Positive

"This inspection was carried out to review in detail the actions taken by the service to improve the quality of care and to confirm that the service was now operating safely."

Positive

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

Positive

"Action was not always taken to improve the quality of care as a result."

Positive

"• There was no quality improvement programmes including clinical or internal audit to monitor quality of care and treatment as well as operational processes; there were no systems to identify where action should be taken."

Positive

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

Positive

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

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

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

Positive

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

Positive

"The practice had implemented a system to ensure lessons learned were shared identified themes and took action to improve safety in the practice."

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."

Positive

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

Positive

"For example the practice had carried out fire safety and legionella risk assessments."

Positive

"Practice leaders had oversight of safety alerts incidents and complaints although we found that actions implemented following a complaint or incident were not reviewed to ensure they reduced the likelihood of the same events occurring again."

Positive

"Although lessons learnt had been documented and shared there was minimal evidence to portray changes that had been implemented as a result of safety incidents."

Positive

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

Positive

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

Positive

"• The practice had strengthened their systems to manage risk so that safety incidents were less likely to happen."

Positive

"There was a lack of clinical and nonclinical meetings to discuss issues learning or to receive feedback from staff regarding safety events."

Positive

"During this inspection we found there were comprehensive risk assessments in relation to safety issues."

Positive

"• The practice monitored and reviewed safety using information from a range of sources."

Positive

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

Neutral

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

Neutral

"Continue to develop systems to ensure that learning from safety events and complaints results in change where required."

Positive

"Monitoring care and treatment There was now a system in place to assess monitor and identify the quality and safety of the service."

Positive

"Staff received uptodate safeguarding and safety training at a level appropriate to their role."

Positive

"• There were no systems in place to assess monitor or identify improvements to the quality and safety of the service."

Positive

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

Positive

"• The practice had systems to manage risk so that safety incidents were less likely to happen."

Positive

"The risk assessment stated this was to be done as a priority and highlighted that a lack of staff knowledge of fire safety would be putting staff and patients at potential risk."

Positive

"Whilst procedures in relation to safety alerts had been reviewed we found evidence that previous alerts had not been actioned and therefore continued to have the potential to adversely impact on patient care."

Positive

"The system to manage significant events and patient safety risks was not effective."

Positive

"Lessons learned and improvements made At our previous inspection we found that there was a process for receiving and acting on Medicines and Healthcare products Regulatory Authority MHRA and Central Alerting System CAS safety alerts that was not being followed."

Positive

"• A lead clinician and pharmacist had reviewed all patient safety notifications and relevant notifications to GP practices were disseminated to staff with clear instructions about the action required."

Positive

"At our most recent inspection we found that effective consideration had yet to be given to this patient safety alert."

Positive

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

Positive

"• All staff had received fire safety awareness training."

Positive

"• The lead pharmacist had fully reviewed and updated the statement of purpose relating to safety alerts received into the practice."

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

"Track record on safety The practice did not have a proactive safety record."

Positive

"• There were processes to conduct safety risk assessments; however there was a lack of evidence at the inspection to demonstrate that any had been completed for the practice."

Positive

"The safety of care for older patients was not a priority and there were limited attempts at measuring safe practice."

Positive

"The provider did not do all that was practicable to assess monitor and mitigate the risks relating to the health safety and welfare of service users and others who may be at risk which arise from the carrying on of the regulated activities."

Positive

"• Clinical staff were not used in a way that ensured patient’s safety was always protected."

Positive

"We felt the trigger for reporting a significant event or patient safety issue was not understood by the staff."

Positive

"• A process was being established to ensure safety and medicines were reviewed and actioned on a regular basis MHRANICAS."

Positive

"• Arrangements in place to receive and comply with patient safety alerts recalls and rapid response reports were ineffective."

Positive

"There was no process to ensure safety alerts were actioned and patients informed if they were at risk."

Positive

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

Positive

"The practice had safety policies which were reviewed and updated on their practice computer system; however some staff spoken with were unable to access them."

Positive

"• There was a process for receiving and acting on Medicines and Healthcare products Regulatory Agency MHRA and Central Alerting System CAS safety alerts that was not being followed."

Positive

"• The system for actioning safety alerts was unclear as there was no lead clinician to assign them to within the practice."

Positive

"There was no process to ensure safety alerts were investigated and patients notified if they were put at risk."

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."

Neutral

"Staff received safety information as part of their induction; however there was no evidence of refresher training."

Neutral

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

Positive

"It was not possible to establish if there was an effective system in place to safeguard service users from abuse and improper treatment."

Positive

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

Positive

"• The practice had implemented systems to safeguard patients from abuse however we found there were areas within their process that required strengthening."

Positive

"Safety systems and processes The practice had clear systems to keep people safe and safeguarded from abuse and improper treatment."

Positive

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

Positive

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

Positive

"• Medicine that was known to be open to misuse abuse and dependence had been audited."

Positive

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

Positive

"• The practice actively promoted equality and diversity."

Neutral

"Staff had received equality and diversity training."

Positive

"Complaints were not handled in a timely manner; investigation did not identify what caused the complaint and no action was taken to prevent similar complaints."

Positive

"Practice leaders had oversight of safety alerts incidents and complaints although we found that actions implemented following a complaint or incident were not reviewed to ensure they reduced the likelihood of the same events occurring again."

Positive

"We found that actions had been implemented following a complaint or incident however the actions were not reviewed to ensure they reduced the likelihood of the same events occurring again."

Positive

"Complaints were not handled in a timely manner; investigation did not identify what caused the complaint and no action was taken to prevent similar complaints."

Positive

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

Positive

"• The complaint policy and procedures were in line with recognised guidance."

Positive

"• Patients who made a complaint were receiving a timely response."

Positive

"A complaint we viewed showed one patient had been seen by five different GPs the fifth consultation resulting in a referral to the acute hospital where they were admitted the same day."

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

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

Positive

"• There was stronger leadership and governance in place and the leaders had clear oversight of clinical performance and risks to patients."

Positive

"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 had now been put in place."

Positive

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

Positive

"• There was stronger leadership and governance in place and the leaders had a clear oversight of clinical performance and risks to patients."

Positive

"Staff were unable to describe the governance or the processes to manage current and future performance arrangements for the practice."

Positive

"• Some staff spoken with remained unaware of any changes to the governance or the processes to manage current and future performance arrangements for the practice."

Positive

"We identified significant concerns relating to governance and managing risk."

Neutral

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

Neutral

"Regular reviews and identified improvements were to be discussed at the governance meetings."

Positive

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

Positive

"Leadership capacity and capability The delivery of highquality care was not assured by the leadership governance or culture at the practice."

Positive

"• The practice had no clear leadership structure insufficient leadership capacity and limited formal governance arrangements."

Neutral

"Governance arrangements The governance arrangements and their purpose were unclear and there was a lack of clarity about authority to make decisions and how individuals were held to account."

Positive

"• Quality and sustainability were discussed in relevant meetings where all staff had sufficient access to information."

Neutral

"We found the sustainability of the changes made since the last inspections was unclear."

Positive

"Clinical and management support was also available from Virgin Care Services Limited with a view to new management staff receiving mentoring to try to ensure sustainability of any local structure changes."

Positive

"However there was a sustainability project in place with a clear plan for the current clinical leader to mentor any new staff employed in a leadership capacity."

Positive

"They had started working closely with staff and others to make sure that staff had shared ownership of improvements to the policies and procedures with a view to sustainability as the service stabilised."

Positive

"• Quality and sustainability continued to receive insufficient coverage in relevant meetings at all levels."

Positive

"• The impact of service changes on the quality and sustainability of care is not understood."

Positive

"There were no examples of leaders making a demonstrable impact on the quality or sustainability of services."

Positive

"Monitoring care and treatment The practice now had a programme of quality improvement activity and routinely reviewed the effectiveness and appropriateness of the care provided however we found there were still areas that needed reviewing."

Positive

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

Positive

"• There was no quality improvement programmes including clinical or internal audit to monitor quality of care and treatment as well as operational processes; there were no systems to identify where action should be taken."

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

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

Neutral

"Requirements relating to the prevention and control of infection were not being met."

Positive

"• Some staff told us they received ongoing training that included: safeguarding infection control and basic life support."

Neutral

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

Positive

"Participation in audits and quality assurance processes was limited."