What is the Quality of Facilities at West Street Surgery

Positive

"• The practice’s uptake for breast and bowel cancer screening was above the national average."

Positive

"The practice also employs two female senior nurse practitioner prescribers two female practice nurses and one female practice nurse that also works as a community matron for the practice providing home visits to patients unable to attend the practice."

Positive

"The practice also employs two female senior nurse practitioner prescribers two female practice nurses and one female practice nurse that also works as a community matron for the practice providing home visits to patients unable to attend the practice."

Positive

"The practice also employs two female senior nurse practitioner prescribers two female practice nurses and one female practice nurse that also works as a community matron for the practice providing home visits to patients unable to attend the practice."

Positive

"• The practice employed a practice nurse who also provided a community matron role and a GP visited any housebound patients as appropriate."

Neutral

"• The practice employed a practice nurse who also carried out a role as a community matron for the practice and followed up on older patients discharged from hospital."

Neutral

"• The practice nurse who also carried out a community matron role for the practice followed up patients who had received treatment either in hospital or through the out of hours services for an acute exacerbation of asthma."

Positive

"There are two nurse practitioners and four practice nurses who are supported by a health care assistant."

Positive

"They told us that they were taking action to improve these results including by increasing GP awareness of the issues and by directing patients to nurse led services where appropriate."

Positive

"The practice nurse was the infection control clinical lead who liaised with the local infection prevention team to keep up to date with best practice."

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

"There were also nurse led clinics for patients with respiratory conditions such as asthma and chronic obstructive pulmonary disease coronary heart disease and diabetes."

Positive

"• The practice shared relevant information with other services in a timely way for example when referring patients to other services and communication with the district nurse and health visitor."

Positive

"Our judgement of the quality of care at this service is based 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."

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

"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

"• We found gaps in record keeping to support appropriate monitoring of the cold chain as vaccination fridge temperatures were not consistently recorded."

Positive

"However we found gaps in the record keeping to support the appropriate monitoring of the cold chain."

Positive

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

Positive

"Fridge temperatures were not consistently recorded to support appropriate monitoring of the cold chain."

Positive

"People with suspected high blood pressure were offered ambulatory blood pressure monitoring and patients with atrial fibrillation were assessed for stroke risk and treated as appropriate."

Positive

"• Arrangements were in place for planning and monitoring the number and mix of staff needed to meet patients’ needs including planning for holidays sickness busy periods and epidemics."

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

"However some risk management processes such as managing high risk medication monitoring children who fail to attend a hospital appointment DNA needed strengthening."

Positive

"However we found that the practice had not always updated patient records with monitoring information when they received high risk medications."

Positive

"However systems relating recording of monitoring information of patients receiving high risk medication historic safety alerts children not attending hospital appointments DNA and communication with the out of hours provider OOH needed strengthening."

Positive

"For example the practice had worked with the NHS Bedfordshire Clinical commissioning Group CCG and piloted a monitoring tool to support safe care for vulnerable patients at high risk of medicines related harm."

Positive

"• There were procedures in place for monitoring and managing risks to patient and staff safety."

Positive

"For example the practice had worked with the CCG and piloted a monitoring tool to support safe care for vulnerable patients at high risk of medicines related harm."

Positive

"• The practice had worked with the CCG and piloted a monitoring tool to support safe care for vulnerable patients at high risk of medicines related harm."

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

"• Ensure a system is implemented to ensure that all monitoring results of patients receiving repeat high risk medications are recorded within patient records."

Positive

"There is a large car park outside the surgery with parking for people living with disabilities available."

Positive

"There is a large car park outside the surgery with parking for people living with disabilities available."

Positive

"There is a large car park outside the surgery with parking for people living with disabilities available."

Positive

"There is free car parking outside the surgery with adequate disabled parking available."

Positive

"• The practice had conducted risk assessments for fire and health and safety and had plans for completing any actions identified."

Positive

"• There was no evidence of risk assessments regarding the premises health and safety and fire at the time of our inspection."

Positive

"• The provider had not done all that was reasonably practicable to mitigate risks to the health and safety of service users receiving care and treatment."

Neutral

"We observed the practice to be clean and tidy with no visible health and safety risks."

Positive

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

Positive

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

Neutral

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

Positive

"• Health and safety audits and an infection prevention and control audit had been completed."

Neutral

"• There were some systems in place to manage infection prevention and control however further improvements were required."

Neutral

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

Positive

"• There were no cleaning schedules in place for nonsingle use nursing equipment."

Positive

"For example there was no current infection control lead in place and the practice was unable to provide evidence of completed cleaning schedules for the premises."

Positive

"However reception staff were required to clean patient toilets when necessary and the practice did not ensure that appropriate cleaning supplies were available for staff to use."

Neutral

"Cleaning was not being completed appropriately and there was no oversight of what cleaning had been completed."

Positive

"• The practice held regular review meetings involving district nurses GP’s and the local palliative care nurses for people that required end of life care and those on the palliative care register."

Positive

"• The practice regularly reviewed patients with palliative care needs and held review meetings with the community and the palliative care nurses."

Positive

"• Clinical staff told us that they used the templates on the electronic system to assist with the assessment of patients with long term conditions for example the palliative care template."

Positive

"There was no evidence of onetoone meetings appraisals coaching and mentoring or formal clinical supervision taking place."

Neutral

"In particular appraisals and clinical supervision was not completed."

Positive

"This included ongoing support onetoone meetings coaching and mentoring clinical supervision and facilitation and support for revalidating GPs."

Positive

"• The practice was able to demonstrate that they received acted on and learned from external safety events as well as patient and medicine safety alerts."

Positive

"We reviewed a recent safety alert related to managing patients receiving a particular medicine to treat a form of diabetes and found appropriate actions had been taken as recommended."

Positive

"The practice had shared care agreements in place with secondary care for patients receiving Warfarin an anticoagulant medicine to reduce the risk of blood clots forming and adult patients receiving oral Methotrexate a medicine used to treat rheumatoid arthritis."

Positive

"• The practice held regular review meetings involving district nurses GP’s and the local palliative care nurses for people that required end of life care and those on the palliative care register."