What is the Quality of Safety at St Thomas Road Surgery

Positive

"The practice told us that there were significant challenges with compliance due to the cultural beliefs of the practice’s population regarding diet however they had recently arranged an educational event and were planning further events to help patients understand the importance of managing their condition."

Positive

"For example we saw that there was information available on diet smoking cessation alcohol consumption contraception staying warm in winter and about travel."

Positive

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

Positive

"• The practice’s GP patient survey results were below local and national averages for questions relating to kindness respect and compassion."

Positive

"However patients were observed to be treated with kindness and recent practice surveys showed positive patient feedback."

Positive

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

Positive

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

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

"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

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

Positive

"The practice used a groupwide policy and protocol for repeat prescribing and we were assured that this was followed in respect of a clinician authorising all prescriptions."

Positive

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

Positive

"Patients told us that they were treated with kindness respect and dignity by all the staff at the practice."

Positive

"Some of the cards referred to GPs and staff by name singling out individual examples of kindness care and compassion."

Positive

"We also saw that staff treated patients with kindness and respect and maintained confidentiality."

Positive

"Neither was there any other information advising patients to respect privacy of others who were at the reception desk."

Positive

"The areas where the provider must make improvements are: • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care."

Positive

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

Positive

"We rated the practice as Inadequate for providing wellled services because: • The delivery of highquality care was not assured by the leadership governance or culture in place • There was a lack of systems for identifying capturing and managing issues and risks."

Positive

"Governance arrangements There were clear responsibilities roles and systems of accountability to support good governance and management."

Positive

"We saw that structures processes and systems to support good governance were in place at provider level."

Positive

"The practice was rated requires improvement for providing wellled services as governance arrangements were not always operated effectively."

Positive

"The provider s finance HR recruitment senior leadership data analytics and governance teams are based within the Central Support Centre however there are no occupational health services based inhouse."

Neutral

"All staff had received information governance training."

Positive

"The areas where the provider must make improvements are: • Establish effective systems and processes within the practice to ensure good governance in accordance with the fundamental standards of care."

Positive

"• Structures processes and systems to support good governance and management were clearly set out but not always understood or effective."

Positive

"Governance arrangements There were identified responsibilities roles and systems of accountability to support good governance and management."

Positive

"• Practice leaders were supported by the organisation and attended quarterly performance meetings and clinical governance meetings with the organisational leadership team."

Positive

"However some governance systems and processes were not always operated effectively."

Positive

"• The governance and management of partnerships and most joint working arrangements enabled coordinated personcentred care."

Positive

"Governance arrangements The practice had a governance structure designed to provide assurance to patients and the CCG that the service was operating safely and effectively."

Positive

"This recognises the significant improvements that have been 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

"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

"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

"– 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

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

Positive

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

Positive

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

Positive

"A chaperone is a person who might be present during a consultation when an intimate examination is taking place to ensure that patients’ rights to privacy are protected."

Positive

"One comment card drew our attention to the lack of privacy at the reception desk."

Positive

"Neither was there any other information advising patients to respect privacy of others who were at the reception desk."

Positive

"The practice learned and shared lessons identified themes and acted 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 established policies procedures and activities to ensure safety and assured themselves that they were operating as intended."

Positive

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

Positive

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

Positive

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

Positive

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

Positive

"• The practice conducted safety risk assessments including those for fire Legionella Legionella is a term for a particular bacterium which can contaminate water systems in buildings and general health and safety issues."

Positive

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

Positive

"• There was an effective system in place for receiving and acting on patient and medicine safety alerts."

Positive

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

Positive

"It had a range of safety policies which were regularly reviewed and staff received safety information as part of their induction and ongoing training programme."

Positive

"• The practice had a number of comprehensive risk assessments related to health and safety which were groupwide and used for all locations managed by the provider."

Neutral

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

Positive

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

Positive

"Learning and improvement from safety incidents Our review of the records of SERs that had occurred during the last two years showed that the practice took action to address any concerns and learned from them as a result."

Positive

"Monitoring safety and responding to risk The practice had systems processes and policies in place to manage and monitor risks to patients staff and visitors to the practice."

Positive

"Health and safety information was displayed for staff to see and there was an identified health and safety representative."

Positive

"The practice was consistent with its approach to dealing with safety incidents over time."

Positive

"Reliable safety systems and processes including safeguarding The practice had systems to manage and review risks to vulnerable children young people and adults."

Positive

"The practice also had a health and safety policy."

Positive

"This demonstrated that staff safety and wellbeing was treated a priority by the practice."

Positive

"They could recognise signs of abuse and staff were aware of the lead clinician."

Positive

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

Positive

"People whose circumstances make them vulnerable: • The practice were aware of their population needs and had provided additional training for staff on different ways to recognise signs of abuse in vulnerable adults and children."

Positive

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

Positive

"Staff knew how to recognise signs of abuse in vulnerable adults and children."

Positive

"Staff knew how to recognise signs of abuse in older people vulnerable adults and children."

Positive

"For example we noted that there was a zero tolerance policy in place in relation to abuse or violence towards staff and this was overtly publicised in the practice and on the website."

Positive

"• The premises were clean and infection control guidance was being followed."

Positive

"An infection control policy and supporting procedures were available for staff to refer to which enabled them to undertake measures in their everyday work to help control infection."

Positive

"Cleanliness and infection control We found the practice to be clean and tidy on the day of our inspection."

Positive

"For example one of the nursing team had lead responsibility for infection control and the senior advanced nurse practitioner ANP coordinated the delayed discharge initiative."

Neutral

"They had undertaken further training to enable them to provide advice on the practice infection control policy and carry out staff training."

Neutral

"All staff received induction training about infection control specific to their role and received annual updates."

Neutral

"We saw evidence that the lead staff member had carried out a quarterly infection control inspection checklist."

Neutral

"Practice staff met with a health visitor to discuss any concerns regarding families children and young people."

Positive

"There were weekly meetings with the health visitor during which any risks to vulnerable children were reviewed."

Positive

"• The practice actively promoted equality and diversity."

Neutral

"Staff had received equality and diversity training."

Positive

"Tackling inequity and promoting equality The practice had recognised the needs of different groups in the planning of its services."

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

"• The practice did not have a poster or information visible in the waiting area about how to complain however information about how to make a complaint or raise concerns was available at the reception desk."

Positive

"Patients could then write the complaint in their chosen language."

Positive

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

Positive

"Any action arising from complaints was also taken for example we saw that the chairs in the waiting room had been replaced following a complaint that they were dirty."

Positive

"There was information on the practice website although this was limited to asking people to make a complaint in writing."

Positive

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

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 comprehensive 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

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