What is the Quality of Safety at Kirby Road Surgery

Positive

"• Risk assessments had been completed for health and safety security and fire safety."

Positive

"• There had been no health and safety risk assessments completed."

Positive

"• There were concerns with health and safety in the practice."

Positive

"The practice 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 Legionella is a term for a particular bacterium which can contaminate water systems in buildings."

Positive

"The practice had systems in place for notifiable safety incidents and ensured this information was shared with staff to ensure appropriate action was taken • The practice proactively sought feedback from staff and patients which it acted on."

Positive

"We saw evidence that appropriate action was taken to improve safety in the practice."

Positive

"Overview of safety systems and processes The practice had clearly defined and embedded systems processes and practices in place to keep patients safe and safeguarded from abuse which included: • Arrangements were in place to safeguard children and vulnerable adults from abuse."

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 learnt were shared to make sure action was taken to improve safety in the practice."

Positive

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

Positive

"We reviewed safety records incident reports MHRA Medicines and Healthcare products Regulatory Agency alerts patient safety alerts and minutes of meetings where these were discussed."

Positive

"There was a health and safety policy available with a poster in the reception office which identified local health and safety representatives."

Positive

"In addition staff received training that included: safeguarding fire safety awareness basic life support and information governance."

Neutral

"This covered such topics as safeguarding infection prevention and control fire safety health and safety and confidentiality."

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 cessation."

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: • There were flaws in the leadership and governance of the practice."

Positive

"In particular we found: • Significant concerns in the leadership and governance of the practice."

Positive

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

Positive

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

Neutral

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

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

"Improvements were made to the quality of care as a result of complaints and concerns."

Positive

"There was no other quality improvement activity demonstrated in the practice."

Positive

"There was evidence of quality improvement including clinical audit."

Positive

"They also told us they were satisfied with the care provided by the practice and said their dignity and privacy was respected."

Positive

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

Positive

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

Positive

"Overview of safety systems and processes The practice had clearly defined and embedded systems processes and practices in place to keep patients safe and safeguarded from abuse which included: • Arrangements were in place to safeguard children and vulnerable adults from abuse."

Positive

"The practice 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 Legionella is a term for a particular bacterium which can contaminate water systems in buildings."

Positive

"One of the practice nurses was the infection control clinical lead who liaised with the Are services safe?"

Neutral

"• Annual infection control audits were undertaken and we saw evidence that action was taken to address any improvements identified as a result."

Neutral

"There was an infection control protocol in place and staff had received up to date training."

Neutral

"Annual infection control audits were undertaken and we saw evidence that action was taken to address any improvements identified as a result."

Positive

"Patients said they felt the practice offered an excellent service and staff were helpful caring and treated them with dignity and respect."

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

Positive

"They also told us they were satisfied with the care provided by the practice and said their dignity and privacy was respected."

Positive

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

Positive

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

Positive

"For example we saw that when the practice received a complaint from a patient who was dissatisfied with the information they received regarding medication changes the practice discussed the complaint and reviewed processes following the incident to reduce the risk of recurrence."

Positive

"Another event was recorded followed a complaint regarding the wording of correspondence sent to patients."