What is the Quality of Safety at Five Elms Medical Practice

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

"For instance we found that when the lead GP intended to close a particular element of the system they sometimes exited the system entirely which mean they had to sign in again to continue working."

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

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

Positive

"• The practice used information technology systems to monitor and improve the quality of care but following the change of computer systems."

Positive

"• The practice considered the impact on the quality of care of service changes or developments and sought to develop solutions where concerns were identified."

Positive

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

Positive

"This recognises the improvements made to the quality of care provided by the 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

"• Undertake regular health and safety risks assessments."

Positive

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

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

"• There was a process to identify understand monitor and address current and future risks including risks to patient safety but the practice had not yet addressed some of the risks identified including the absence of patient alerts on the computer system."

Positive

"The practice learned and shared lessons identified themes and took action to improve safety in the practice."

Positive

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

Positive

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

Positive

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

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

"• There were risk assessments in relation to safety issues."

Neutral

"This helped it to understand risks and gave a picture of safety that led to safety improvements."

Positive

"From the sample of documented examples we reviewed we found there was an effective system for reporting and recording significant events; lessons were shared to make sure action was taken to improve safety in the practice."

Positive

"• We saw evidence that lessons were shared and action was taken to improve safety in the practice."

Positive

"• The practice had a variety of other risk assessments to monitor safety of the premises such as control of substances hazardous to health and infection control and legionella."

Positive

"There was no effective system for managing issues and risks arising from inadequate arrangements for chaperoning safeguarding fire safety and infection control."

Positive

"This indicated that quality and safety were not a priority for the leadership."

Positive

"• We reviewed safety records incident reports patient safety alerts and minutes of meetings where significant events were discussed."

Positive

"This included training and support and training for all staff around communicating with patients about notifiable safety incidents."

Positive

"• Evidence showed that patient safety alerts were being received and acted upon."

Positive

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

Positive

"• Staff received training that included: safeguarding fire safety awareness basic life support and information governance."

Positive

"For instance chaperoning and safeguarding arrangements had been reviewed and staff had received training around fire safety and infection prevention and control."

Positive

"When there were unintended or unexpected safety incidents reviews and investigations were not thorough enough and lessons learned were not communicated widely enough to support improvement."

Positive

"Staff told us that openness and transparency about safety was encouraged; they understood and fulfilled their responsibilities to raise concerns and report incidents and near misses."

Positive

"There was no effective system for managing issues and risks arising from inadequate arrangements for chaperoning safeguarding fire safety and infection control."

Positive

"This indicated that quality and safety were not a priority for the leadership."

Positive

"For instance the practice had worked with NHS management to ensure plans to improve fire safety arrangements at the premises were followed through and we also saw that the practice manager had sought support to put practice specific policies in place to govern activities."

Positive

"This included concerns around fire safety procedures and risk assessments."

Positive

"For example all fire extinguishers had been serviced and fire safety training had been undertaken."

Positive

"This included training and support and training for all staff around communicating with patients about notifiable safety incidents."

Positive

"We reviewed safety records incident reports patient safety alerts and minutes of meetings where these were discussed."

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."

Positive

"For instance chaperoning and safeguarding arrangements had been reviewed and staff had received training around fire safety and infection prevention and control."

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 governance structure of the practice meant the management team did not have complete oversight of possible risks to practice."

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."

Neutral

"• At this inspection we saw evidence that all staff had received information governance training and that staff personnel files included signed confidentiality agreements."

Neutral

"• Staff had received training in confidentiality and information governance and we saw that all staff personnel files included signed confidentiality agreements."

Positive

"We also issued requirement notices to the provider in respect of safe care and treatment good governance staffing issues and concerns around the employment and fitness of proper persons."

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

"• At this inspection we found that practice management had developed a governance framework to support the practice in delivering its mission."

Neutral

"New staff had had documented induction programmes • The practice had recently reviewed all policies and procedures to govern activity and had begun to hold and document regular governance meetings."

Positive

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

Positive

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

Positive

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

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 below local and national averages for questions relating to kindness respect and compassion."

Positive

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

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

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

Positive

"Privacy and dignity Are services caring?"

Positive

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

Positive

"We issued a requirement notice in respect of these findings."

Positive

"We issued a requirement notice in respect of these issues."

Positive

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

Positive

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

Positive

"We also issued requirement notices to the provider in respect of safe care and treatment good governance staffing issues and concerns around the employment and fitness of proper persons."

Positive

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

Positive

"• The practice actively promoted equality and diversity."

Neutral

"Staff had received equality and diversity training."

Positive

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

Positive

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

Positive

"• Patients could get information about how to complain in a format they could understand and we saw that the practice handled complaints in accordance with its complaint handling process."

Positive

"For example we reviewed a complaint from a patient who had experienced a delay in receiving an appointment when they were referred to a secondary provider for further tests."

Positive

"We looked at practice records and found that each complaint recorded had been handled in line with practice procedure."

Positive

"The practice had investigated the circumstances around the complaint and found that a locum GP had not passed the details of the referral to the administration team."

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 practice had investigated the complaint and had identified a shortcomings in the procedure used to book patient transport."

Positive

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

Positive

"Monitoring care and treatment The practice had a programme of quality improvement activity and routinely reviewed the effectiveness and appropriateness of the care provided."

Positive

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

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

"There was evidence of quality improvement including clinical audit: • There had been six clinical audits commenced in the last two years two of these were completed audits where the improvements made were implemented and monitored."

Positive

"• The practice had a variety of other risk assessments to monitor safety of the premises such as control of substances hazardous to health and infection control and legionella."

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."