What is the Quality of Safety at Ashgate Manor

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

"• It had a clear vision with quality and safety as its top priority."

Positive

"The service had systems in place for knowing about notifiable safety incidents and ensured this information was shared with staff to ensure appropriate action was taken."

Positive

"This consisted of five objectives; patient safety focus on prevention and selfcare supporting our workforce good governance and integration through partnership."

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

"• Significant events and incidents were reviewed at the monthly quality and patient safety subcommittee meeting."

Positive

"Patient satisfaction patient safety friends and family test results and healthwatch information were also discussed."

Positive

"• Staff told us if they had been affected by significant events they reported the event including concerns regarding patient safety or any other incidents via an electronic system."

Positive

"Various topics were discussed including patient satisfaction patient safety friends and family test results and healthwatch information was also reviewed."

Neutral

"• The provider had a corporate induction programme for newly appointed members of staff that covered such topics as information governance fire safety health and safety and equality and diversity."

Positive

"• It had a clear vision with quality and safety as its top priority."

Positive

"The service had systems in place for knowing about notifiable safety incidents and ensured this information was shared with staff to ensure appropriate action was taken."

Positive

"This consisted of five objectives; patient safety focus on prevention and selfcare supporting our workforce good governance and integration through partnership."

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

"• Serious incidents and patient safety incidents were reviewed at the monthly quality and patient safety subcommittee meeting."

Positive

"The provider 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

"Guidance had been issued to staff via the clinical update on the importance of safety netting and recording the information in the patients’ notes."

Positive

"A robust safety netting advice system was implemented following these incidents."

Positive

"Patient satisfaction patient safety friends and family test results and Healthwatch information were also discussed."

Positive

"• Staff told us if they had been affected by significant events they reported the event including concerns regarding patient safety or any other incidents via the electronic ‘Datix’ system."

Positive

"We saw that the provider had identified that a lack of adequate safety netting had been judged as a contributory factor in a number of significant events."

Positive

"We reviewed the outcome of two complaints and one serious incident which highlighted the need for improved safety netting for patients."

Positive

"Various topics were discussed including patient satisfaction patient safety friends and family test results and Healthwatch information was also Are services wellled?"

Positive

"The provider was not assessing the risks to the health and safety of service users of receiving the care or treatment or doing all that is reasonably practicable to mitigate any such risks."

Neutral

"• The provider had a corporate induction programme for newly appointed members of staff that covered such topics as integrated clinical governance information governance fire safety health and safety and equality and diversity."

Positive

"• It had a clear vision with quality and safety as its top priority."

Positive

"The service had systems in place for knowing about notifiable safety incidents and ensured this information was shared with staff to ensure appropriate action was taken."

Positive

"This consisted of five objectives; patient safety focus on prevention and selfcare supporting our workforce good governance and integration through partnership."

Positive

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

Positive

"The provider 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 provider employed agency nurse advisors who were clinically trained in NHS Pathways to ensure there was adequate clinical cover within the call centre to ensure the safety of patients."

Positive

"DHU employed agency nurse advisors who were clinically trained in NHS Pathways to ensure there was adequate clinical cover within the call centre to ensure the safety of patients."

Positive

"• There was an open and transparent approach to safety and an effective system in place for reporting and recording serious incidents."

Positive

"The updates also included safety netting in primary care information for topics such as meningitis influenza summary care records unexpected patient deaths antibiotic prescribing and toxbase."

Positive

"During our inspection a member of staff showed us where policies and procedures could be found we saw evidence of a health and safety policy and a COSHH control of substances hazardous to health policy on the intranet which was available for all staff."

Positive

"The final outcome of the NHS Pathways clinical assessment was explained to the patient and in all cases patients were given safety netting advice about what to do should their condition worsen."

Positive

"• Staff told us if they reported serious incidents including concerns regarding patient safety or any other incidents via an electronic ‘Datix’ reporting system."

Positive

"Various topics were discussed including patient satisfaction patient safety friends and family test results and healthwatch information was also reviewed."

Neutral

"• The provider had a corporate induction programme for newly appointed members of staff that covered such topics as integrated clinical governance information governance fire safety health and safety equality and diversity."

Positive

"There were robust systems in place to help ensure patient safety through learning from incidents the safe management of medicines and good infection prevention and control."

Positive

"The establishment of GP Chambers to help mitigate the increasing cost of outofhours insurance indemnity showed a positive approach to maintaining the safety of patients and the security of the outofhours GP service provision."

Positive

"For example staff had undertaken training in verification of patient death end of life care domestic abuse awareness dementia awareness decision making for patients at end of life and foundations in palliative care which covered pain and symptom control and bereavement."

Positive

"This system enabled referrals to be made where the concerns for the patient did not relate to suspected abuse but related to care needs or welfare of the patient."

Positive

"For example staff had undertaken training in varying aspects of end of life care dementia awareness and domestic abuse awareness."

Positive

"• There were robust safeguarding systems in place for both children and adults at risk of harm or abuse as well as frequent callers to the service."

Neutral

"We also saw evidence of annual infection control audits which were carried out for each vehicle at each location."

Neutral

"• All staff had completed infection control training and were provided with infection control updates in the clinical update newsletter for example information on hand hygiene below elbows and information from the World Health Organisation – Who Saves LivesClean Your Hands."

Positive

"The provider 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

"There was an infection control clinical lead nurse who was responsible for carrying out the infection control audits."

Positive

"Annual infection control audits were completed for all primary care centres where patients were seen."

Neutral

"Information about infection control updates was included in the clinical update newsletter for example information on hand hygiene below elbows and information from the World Health Organisation – Who Saves LivesClean Your Hands."

Positive

"The provider 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

"Other members of staff we spoke with were ‘Dignity Champions’ and had registered for this role as part of the Dignity in Care campaign which aimed to put dignity and respect at the heart of all UK care services and was supported by the national Dignity Council."

Positive

"• In the comment cards patients completed for us they said they were treated with dignity and respect by helpful polite and caring staff."

Positive

"However we spoke with numerous members of the nursing team who through discussion demonstrated their commitment to their role and were able to tell us how they delivered a high level of patient care and treated patients with dignity and respect at all times."

Positive

"• We saw evidence of a ‘Derby City ‘Dignity Campaign’ certificate of achievement’ in recognition of their work to promote dignity and respect."

Positive

"• Through the comment cards patient completed for us they said they were treated with compassion dignity and respect."

Positive

"Comments told us that patients felt that staff were caring and they were treated with dignity and respect."

Positive

"• Staff treated patients with kindness and respect and maintained patient and information confidentiality at all times."

Positive

"• We saw staff treated patients with kindness and respect and maintained patient and information confidentiality at all times."

Positive

"Our findings Kindness dignity respect and compassion We observed members of staff were courteous and very helpful to patients and treated them with dignity and respect during our inspection."

Positive

"• Patients said they were treated with dignity and respect by helpful polite and caring staff."

Positive

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

Positive

"• We saw evidence of a ‘Derby City ‘Dignity Campaign’ certificate of achievement’ in recognition of their work to promote dignity and respect."

Positive

"Comments told us that patients felt that staff were caring and they were treated with dignity and respect."

Positive

"Patients said they felt the service provided was excellent and found staff were helpful caring and treated them with dignity and respect."

Positive

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

Positive

"We observed that call advisors and clinical advisors spoke with patients in a respectful manner with care and compassion they were confident in the use of the NHS Pathways programme and the patient was involved and supported to answer questions thoroughly."

Positive

"During our inspection we saw various notice boards providing information to call centre staff on topics such as dignity and human rights how to support people with autism unexpected patient death Mental Capacity Act and Deprivation of Liberty Safeguards."

Positive

"Patients and carers we spoke with said staff displayed a kind and caring attitude and we observed patients being treated with respect and kindness whilst their dignity and confidentiality was maintained."

Positive

"We observed examples of good interaction between patients and staff and noted that staff treated patients with respect and kindness and protected their dignity and confidentiality."

Positive

"Without exception we saw that staff acted in a kind and sympathetic manner and maintained the patient’s dignity and confidentiality at all times."

Neutral

"• The provider had a corporate induction programme for newly appointed members of staff that covered such topics as information governance fire safety health and safety and equality and diversity."

Neutral

"• The provider had a corporate induction programme for newly appointed members of staff that covered such topics as integrated clinical governance information governance fire safety health and safety and equality and diversity."

Neutral

"• The provider had a corporate induction programme for newly appointed members of staff that covered such topics as integrated clinical governance information governance fire safety health and safety equality and diversity."

Neutral

"New employees received training in equality and diversity as part of their corporate induction training."

Positive

"Patients who made a complaint were sent a copy of complaints leaflet which was available in a number of different languages."

Positive

"Patients who made a complaint were sent a copy of complaints leaflet which was available in a number of different languages."

Positive

"We looked at one complaint in detail."

Positive

"Patients who made a complaint were sent a copy of a complaints leaflet which was available in a number of different languages for patients whose first language was not English."

Positive

"As part of the complaint investigation calls were listened to and information recorded on a call review document."

Positive

"The was a complaints system and we saw that any learning from those complaints was shared with staff although we noted that the procedures for making a complaint could be made more visible at the Ashgate treatment centre."

Positive

"One of the patients we spoke with said they would not know how to raise a complaint other than by looking on the DHU website."

Positive

"• There was an overarching governance and performance management framework which supported the delivery of the strategy and good quality care."

Positive

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

Positive

"This consisted of five objectives; patient safety focus on prevention and selfcare supporting our workforce good governance and integration through partnership."

Positive

"Significant incidents were investigated by the clinical governance leaddeputy lead and discussed with the Clinical Commissioning Group quality lead."

Neutral

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

Neutral

"At the time of our inspection DHU had a governance structure in place for the evening and overnight district nursing service."

Neutral

"• The provider had a corporate induction programme for newly appointed members of staff that covered such topics as information governance fire safety health and safety and equality and diversity."

Positive

"• There was an overarching governance and performance management framework which supported the delivery of the strategy and good quality care."

Positive

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

Positive

"This consisted of five objectives; patient safety focus on prevention and selfcare supporting our workforce good governance and integration through partnership."

Neutral

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

Neutral

"• The provider had a corporate induction programme for newly appointed members of staff that covered such topics as integrated clinical governance information governance fire safety health and safety and equality and diversity."

Positive

"• There was an overarching governance and performance management framework which supported the delivery of the strategy and good quality care."

Positive

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

Positive

"This consisted of five objectives; patient safety focus on prevention and selfcare supporting our workforce good governance and integration through partnership."

Positive

"Significant incidents and serious incidents were investigated by the clinical governance leaddeputy lead and discussed with the Clinical Commissioning Group quality lead."

Neutral

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

Neutral

"• The provider had a corporate induction programme for newly appointed members of staff that covered such topics as integrated clinical governance information governance fire safety health and safety equality and diversity."

Positive

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

Positive

"DHU had a wide range of quality assurance processes in place to continually monitor and assess the quality of service provision which included a range of audits to help identify and instigate actions to address any shortfalls."

Positive

"DHU had a wide range of quality assurance processes in place to continually monitor and assess the quality of service provision which included a range of audits to help identify and instigate actions to address any shortfalls."

Positive

"We saw evidence that DHU conducted ongoing patient experience questionnaires and used the ‘Friends and Family’ test to help them assess the quality of service provision."