What is the Quality of Facilities at Five Elms Medical Practice

Neutral

"The practice has a practice nurse who provide six sessions per week."

Positive

"The practice had arranged for the trainee health care assistant to receive ongoing mentoring from an experienced practice nurse who had previously been employed by the practice • Staff stated they felt respected supported and valued."

Neutral

"The practice is in the process of recruiting a practice nurse and currently locum nurses provide six sessions per week."

Neutral

"We saw that they were being mentored by an experienced practice nurse during their training programme."

Positive

"This provided access to expert professional advice support and peer mentoring from experienced senior GPs practice managers and nurse practitioners with specialist expertise in quality improvement."

Positive

"This provided access to expert professional advice support and peer mentoring from experienced senior GPs practice managers and nurse practitioners with specialist expertise in quality improvement coordinated by the RCGP."

Positive

"• The practice nurse was the infection prevention and control IPC clinical lead who liaised with the local infection prevention teams to keep up to date with best Are services safe?"

Positive

"• Where a patient’s mental capacity to consent to care or treatment was unclear the GP or practice nurse assessed the patient’s capacity and recorded the outcome of the assessment."

Positive

"GPs and the practice nurse were trained to child protection or child safeguarding level three the health care assistant was trained to level two and all other members of staff were trained to level one."

Neutral

"During our visit we: • Spoke with a range of staff one GP practice nurse practice manager and members of the administration and reception teams and spoke with patients who used the service."

Positive

"• Where a patient’s mental capacity to consent to care or treatment was unclear the GP or practice nurse assessed the patient’s capacity and recorded the outcome of the assessment."

Positive

"GPs and the practice nurse were trained to child protection or child safeguarding level three the health care assistant was trained to level two and all other members of staff were trained to level one."

Positive

"For instance the audit of patients with COPD had been completed jointly by a GP and the practice nurse whilst an audit of patients diagnosed with cancer had been undertaken by a GP and the practice manager."

Neutral

"During our visit we: • Spoke with a range of staff one GP a practice nurse practice manager and two members of the administration team and spoke with patients who used the 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

"We rated the practice as inadequate for effective services because: • The practice did not have adequate systems in place governing the recording monitoring and following up of inadequate screening results."

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."

Positive

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

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."

Positive

"Management monitoring and improving outcomes for people The practice used the information collected for the Quality and Outcomes Framework QOF and performance against national screening programmes to monitor outcomes for patients."

Positive

"Monitoring risks to patients There were procedures for assessing monitoring and managing risks to patient and staff safety."

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 were cleaning schedules and monitoring systems in place."

Positive

"Management monitoring and improving outcomes for people The practice used the information collected for the Quality and Outcomes Framework QOF and performance against national screening programmes to monitor outcomes for patients."

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

"• We looked at arrangements for planning and monitoring the number of staff and mix of staff at the practice and were told that there was a system in place to review staff numbers."

Positive

"The practice is registered with the Care Quality Commission to provide the regulated activities of diagnostic and screening procedures treatment of disease disorder and injury and maternity and midwifery services."

Positive

"• Staff were clear on their roles and accountabilities including in respect of safeguarding and infection prevention and control • Practice leaders had established policies procedures and activities to ensure safety and assured themselves that they were operating as intended."

Positive

"The practice is registered with the Care Quality Commission to provide the regulated activities of diagnostic and screening procedures treatment of disease disorder and injury and maternity and midwifery services."

Positive

"The practice is registered with the Care Quality Commission to provide the regulated activities of diagnostic and screening procedures treatment of disease disorder and injury and maternity and midwifery services."

Neutral

"• Policies to govern activities at the practice had been reviewed and were available to all staff."

Positive

"The practice is registered with the Care Quality Commission to provide the regulated activities of diagnostic and screening procedures treatment of disease disorder and injury and maternity and midwifery services."

Neutral

"• Policies to govern activities at the practice had been reviewed and updated and were available to all staff."

Positive

"• Undertake regular health and safety risks assessments."

Positive

"• There was a health and safety policy available."

Positive

"We saw that there was now a health and safety policy available with a poster in the reception office which identified local health and safety representatives."

Neutral

"At this inspection the practice had developed an induction programme for all newly appointed staff and we saw records which showed this had been used to induct new staff on topics including safeguarding infection prevention and control fire safety health and safety and confidentiality."

Positive

"• The practice’s uptake for breast cancer was in line with the national average but the uptake rate for bowel cancer screening was below the national average."

Positive

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

Positive

"For example we reviewed a complaint from a patient who had been unable to attend an appointment because transport arrangements which they believed the practice had arranged on their behalf had not worked on the day of their appointment."

Positive

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

Neutral

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

Positive

"• Staff were clear on their roles and accountabilities including in respect of safeguarding and infection prevention and control • Practice leaders had established policies procedures and activities to ensure safety and assured themselves that they were operating as intended."

Positive

"• The practice nurse was the infection prevention and control IPC clinical lead who liaised with the local infection prevention teams to keep up to date with best Are services safe?"

Positive

"We saw evidence which showed that the practice had increased the range of elearning training modules that was available to staff for instance by including modules on infection prevention and control and information governance."

Positive

"At this inspection we saw that all staff had now received appropriate training and an infection control audit had recently been undertaken and an infection prevention and control protocol was now in place."

Neutral

"At this inspection the practice had developed an induction programme for all newly appointed staff and we saw records which showed this had been used to induct new staff on topics including safeguarding infection prevention and control fire safety health and safety and confidentiality."

Positive

"People with longterm conditions: This population group was requires improvement for effective because: • The practice had a system in place to in place to invite patients with long term conditions for regular health and medicine reviews but the practice had recognised that this was not always effective."

Positive

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

Positive

"For example following a published guideline on the appropriate use of a medicine used to treat epilepsy we noted that the practice had audited the practice list to identify patients using the medicine and had taken steps to contact ensure these patients were provided with appropriate advice."

Positive

"• The practice had accessible parking facilities a front door which opened automatically and there was step free access to all consulting rooms."

Positive

"• The practice had disabled parking facilities a front door which opened automatically and there was step free access to all consulting rooms."

Neutral

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

Neutral

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

Neutral

"There were cleaning schedules and monitoring systems in place."

Neutral

"We saw a message book which the practice used to communicate with the cleaning contractor."

Neutral

"For instance following the most recent IPC audit which was undertaken by external experts the practice had worked with their cleaning contractor to develop a more detailed cleaning schedule to include a detailed specification for cleaning individual rooms including a list of items and cleaning frequencies."

Positive

"We saw one set of minutes from a meeting with the palliative care team and saw that the findings of the practice audit of its palliative care had been discussed and areas for improvement had been identified."

Positive

"The practice told us this had been discussed in a clinical governance meeting and clinicians had been reminded to consider adding patients to the palliative care register when reviewing care plans."

Positive

"The clinical audits undertaken concerned audits of palliative care diabetes cancer and chronic obstructive pulmonary disorder COPD."

Positive

"For instance although the results of the audit indicated that patients who had deceased during the period of the audit had died in their preferred place of death one patient who had passed away and should have been added the palliative care register had not."

Positive

"The practice told us this had been discussed in a clinical governance meeting and clinicians had been reminded to consider adding patients to the palliative care register when reviewing care plans."