What is the Quality of Safety at West Street Surgery

Positive

"• The practice had limited formal governance arrangements in place and quality improvement methods to assess monitor and improve the quality and safety of the services provided."

Positive

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

Positive

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

Positive

"• The practice had developed logs for complaints significant and safety alerts and these were shared with practice staff at clinical meetings."

Positive

"Track record on safety The practice did not have a good track record on safety."

Positive

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

Positive

"• On the day of inspection the practice was unable to provide evidence of formal risk assessments in relation to safety issues including fire safety."

Positive

"• There was a lack of oversight of complaints significant events and safety alerts."

Positive

"However the practice did not share learning across the staff team or identify themes to improve safety in the practice."

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

"Practice leaders did not have oversight of safety alerts incidents and complaints."

Positive

"For example the practice did not assess the safety and security of both staff and patients when implementing an extended hours service or discuss this with staff."

Positive

"• There was no oversight of the actions taken from safety alerts."

Positive

"• There was no loneworking policy in place to ensure the safety of staff members in the event of working alone at the practice."

Positive

"Following our inspection we were informed by the provider they had revised their process for the management of safety alerts."

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."

Positive

"In particular there was no evidence of oversight or shared learning from complaints incidents significant events or safety alerts."

Neutral

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

Neutral

"• There was no emphasis on the safety and wellbeing of all staff."

Positive

"The practice had risk assessments in place to monitor safety of the premises such as control of substances hazardous to health 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."

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 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

"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

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

Positive

"The practice had systems in place to ensure that when there were unexpected safety incidents: • The practice gave affected people support and explanation."

Positive

"We reviewed safety records incident reports 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

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

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

"The practice had a process in place to act on alerts that may affect patient safety for example from the Medicines and Healthcare products Regulatory Agency MHRA."

Positive

"The practice had a documented flow chart to manager safety alerts."

Neutral

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

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

"• 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

"• We saw evidence of staff treating patients with kindness and compassion."

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

Positive

"• Feedback on the day of inspection showed patients felt they were treated with kindness respect and compassion."

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 harassment discrimination and breaches of their 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

"• The practice had a clear vision to provide the highest quality healthcare for the local population in an open and welcoming environment and treat patients with respect dignity and honesty."

Positive

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

Positive

"Results from the national GP patient survey showed patients felt they were treated with compassion dignity and respect."

Positive

"Patients felt the practice offered a considerate convenient service and staff were attentive caring and had treated them with dignity and respect."

Positive

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

Positive

"• Its aim was to create a partnership between patient and health profession which ensured mutual respect holistic care and continuous learning and training."

Positive

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

Positive

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

Positive

"• The practice had limited formal governance arrangements in place and quality improvement methods to assess monitor and improve the quality and safety of the services provided."

Positive

"We rated the service as inadequate for providing Wellled services because: • The practice had unclear governance and management structures."

Positive

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

Positive

"Governance arrangements There were no clear responsibilities roles and systems of accountability to support good governance and management."

Positive

"This meant that; • Structures processes and systems to support good governance and management were ineffective."

Positive

"However the lack of governance meant that these reviews were not routinely carried out."

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

"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."

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

"• There were no regular whole practice staff meetings to discuss quality of care and sustainability."

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 limited knowledge of data protection and the duty of candour."

Positive

"• The practice had limited formal governance arrangements in place and quality improvement methods to assess monitor and improve the quality and safety of the services provided."

Positive

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

Positive

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

Positive

"• The practice had improved infection control practices."

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

"• There was no infection control lead."

Positive

"The practice had risk assessments in place to monitor safety of the premises such as control of substances hazardous to health infection control and legionella Legionella is a term for a particular bacterium which can contaminate water systems in buildings."

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."

Neutral

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

Positive

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

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."

Neutral

"• Not all 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

"The practice held monthly multidisciplinary team meetings including the health visitor to discuss at risk children and families."