What is the Quality of Safety at Shirley Medical Centre

Neutral

"The provider did not ensure actions were always undertaken following medicines and safety alerts."

Positive

"For example assessments of fire safety emergency lighting and legionella had identified actions that had not been acted upon and there was no system in place to ensure blood tests were reviewed before prescribing high risk medicines."

Neutral

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

Positive

"For example assessments of fire safety emergency lighting and legionella had identified actions that had not all been acted upon and there was no system to ensure that recent blood test results were reviewed before prescribing high risk medicines."

Positive

"This was particularly the case with regards to systems to ensure safety and to ensure that staff were appropriately recruited and trained."

Positive

"• There were processes to manage risks including risks to patient safety but these were not effective for a variety of reasons."

Positive

"For example with monitoring of uncollected prescriptions the risks had not been fully identified with fire safety risks were identified but not acted upon and with recruitment the process had not been consistently implemented."

Positive

"For example with monitoring of uncollected prescriptions the risks had not been fully identified; with fire safety risks were identified but not acted upon; and with recruitment the process had not been consistently implemented."

Positive

"At this inspection we found: • A number of systems to ensure safety were not operating effectively."

Positive

"For example assessments of fire safety emergency lighting and legionella had identified actions that had not all been acted upon."

Positive

"• The practice did improve safety in response to incidents for example fitting a hand rail to a steep flight of stairs to an administrative area after a member of staff tripped."

Positive

"In particular: · Assessments of fire safety emergency lighting and Legionella had identified actions that had not all been acted upon."

Positive

"There was a system for receiving and acting on safety alerts such as patient and medicine safety alerts."

Neutral

"Track record on safety • The practice conducted safety risk assessments but did not always act upon the recommendations."

Neutral

"There were insufficient quantities of medicines to ensure the safety of service users and to meet their needs."

Neutral

"Our key findings across all the areas we inspected were as follows: • The practice had Oxygen and an Automatic External Defibrillator AED in place to ensure the welfare and safety of service users in a medical emergency."

Positive

"Areas for improvement Action the service SHOULD take to improve Be encouraged to have an Automatic External Defibrillator AED to maximise emergency care provision available within the practice and to ensure the welfare and safety of service users."

Positive

"Learning and improvement from safety incidents The practice had an effective system in place for reporting recording and monitoring incidents and significant events."

Positive

"Staff were suitably supported and patient care and safety was a high priority."

Positive

"Information about safety was recorded monitored appropriately reviewed and addressed."

Positive

"The provider had policies and procedures in place for safeguarding infection control and health and safety and a significant event policy and procedure."

Positive

"Staffing levels were maintained and procedures were in place to manage planned and unexpected absences Monitoring safety and responding to risk There were effective and safe systems in place to monitor and respond to risk and to ensure the safety and welfare of staff and the people using the service."

Positive

"Reliable safety systems and processes including safeguarding The practice had policies in place relating to the safeguarding of vulnerable adults child protection and whistleblowing."

Positive

"Incidents related to safety and safeguarding that had occurred were available to see with records of actions taken investigations and final outcomes."

Neutral

"Records of these kinds of event were handled and stored in line with data protection requirements."

Positive

"• Ensure that effective systems and processes are in place to ensure good governance in accordance to fundamental standards of care."

Positive

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

Positive

"Governance arrangements There were clear responsibilities and roles to support good governance and management but a number of systems were not operating as intended."

Positive

"• A number of structures processes and systems had been established to support good governance and management but in a number of cases they were not effective."

Positive

"Governance arrangements The practice had good governance arrangements and an effective management structure."

Positive

"The practice manager was able to explain the importance of maintaining governance structures."

Neutral

"The practice had a number of policies and procedures to govern activity and regular governance meetings had taken place the minutes of which were available to view."

Positive

"Monitoring care and treatment The practice carried out quality improvement activity reviewing various aspects of the care provided."

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

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

Positive

"• Clinical audit had 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

"Listening and learning from concerns and complaints The practice took complaints and concerns seriously and responded to them appropriately to improve the quality of care but did not always follow national guidance as to their responses."

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

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

Positive

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

Positive

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

Positive

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

Positive

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

Positive

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

Positive

"The overarching view was that patients trusted the practice staff and GPs felt confident in the care and treatment on offer and that they were continuously treated with kindness in a caring manner and were always treated with respect."

Positive

"Patients were cared for in a kind and compassionate manner were treated with dignity and respect and at all times."

Positive

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

Positive

"We were told that regular meetings were held with the practice and that the members were encouraged to make comments and suggestions and felt that they had a direct impact on the care and treatment available and were always treated with dignity and respect."

Positive

"Patients were treated with kindness and respect and felt involved in their care decisions."

Positive

"The patients we spoke with were complimentary of the care and service that the practice provided and told us they were treated with dignity and respect."

Positive

"They stated that the GPs were caring and that they were treated with dignity and respect."

Positive

"Treatment rooms were clean and spacious all with couches with curtains to maintain patient’s dignity during examination."

Positive

"We also saw that staff treated patients with kindness and respect and ensured confidentiality was maintained at all times."

Positive

"We observed staff interactions with patients and visitors in the waiting area and at the reception desk and noted that staff ensured respect and dignity at all times."

Positive

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

Positive

"Staff we spoke with were aware of the need to be respectful of patients’ right to privacy and dignity."

Neutral

"GP and nurse consultations were undertaken in consulting rooms which ensured privacy for patients."

Positive

"• The practice had systems to safeguard children and vulnerable adults from abuse but these were not fully documented."

Positive

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

Positive

"Safety systems and processes The practice had systems to keep patients safe and safeguarded from abuse but these were not fully documented or consistently followed."

Neutral

"Staff we talked to understood infection control arrangements relevant to their role."

Neutral

"We were also sent template that the practice planned to use to carry out an infection control audit within two weeks."

Neutral

"In particular: · Annual infection control audits had not been carried out."

Positive

"Risks to patients were assessed and managed in relation to infection control and responding to emergencies."

Positive

"This reduced the risk of cross infection as the refurbishments were in line with infection control guidance."

Positive

"The practice was generally clean and staff had completed infection control training."

Positive

"The provider had policies and procedures in place for safeguarding infection control and health and safety and a significant event policy and procedure."

Positive

"Cleanliness and infection control There were systems in place to reduce the risk and spread of infection."

Positive

"Training undertaken included: infection control and cleanliness basic and advanced life support recognising vulnerable people safe guarding and child protection."

Neutral

"There were records of cleanliness and infection control audits being completed."

Neutral

"For example the nurse was the lead for infection control and the lead GP was the lead for safeguarding."

Positive

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

Positive

"• The complaint policy did not contain all of the details of recognised guidance for example on timelines for final responses."

Positive

"In particular: · The complaint policy did not contain all of the details of recognised guidance for example on timelines for final responses."

Positive

"The practice was very open to learning from concerns or complains and was able to show us that the practice had received one complaint in the past twelve months."

Positive

"A cancer care review is a holistic conversation that assists an individual to raise any issues relating to their cancer or treatment that are impacting on their quality of life or wellbeing and has been demonstrated to improve outcomes for people living with and beyond cancer."

Positive

"Tackling inequity and promoting equality There were arrangements in place to meet the needs of the people for whom English was not the first language."