What is the Quality of Safety at Devon Doctors - Osprey House

Positive

"These covered governance systems; privacy breaches; health and safety in the service; medicine management; infection control; complaints handling; recruitment process; consent to care and treatment; and staff training."

Positive

"Privacy and dignity The service did not consistently respect and promote patients’ privacy and dignity."

Positive

"In particular: • Concerns received from staff and a service user about privacy breaches had not been notified to relevant authorities in a timely manner and assumptions were made as to the outcome of the concern prior to a full and through investigation."

Neutral

"The registered person had not ensured the privacy of service users."

Positive

"Areas highlighted for improvement included improving the safety of triage queue as there were still concerns with evenings and Saturday afternoons."

Positive

"Risks to patients • Staff considered there was a potential risk to patient safety during the out of hours period OOH on the weekends."

Positive

"• Staff were able to explain the process for safety calling to inform patients that there was a delay in their care and treatment."

Positive

"The committees covered areas such as risk and safety quality safeguarding and performance along with senior leadership meetings."

Positive

"• Areas discussed at these meetings included safety calling and the need to reduce these so that they would only be used by exception rather than being an accepted way of working."

Positive

"Data provided by the provider showed that safety calling was completed in accordance with the targets the provider had set for this."

Positive

"These covered governance systems; privacy breaches; health and safety in the service; medicine management; infection control; complaints handling; recruitment process; consent to care and treatment; and staff training."

Positive

"When the safety calls were made staff were unable to provide information on how soon a patient would be contacted by a clinician."

Positive

"This included how the provider intended to plan and safety deliver services to meet patients’ needs."

Positive

"Data provided showed that safety calling was completed in accordance with the targets which the provider had set for this."

Positive

"Risks to patients The systems to assess monitor and manage risks to patient safety were not effective."

Positive

"We were not assured that systems to monitor and review safety to ensure patient safety were managed effectively."

Positive

"Some processes and procedures related to fire safety needed improvement and we found other areas where safety checks had not been completed or the providers procedures had not been followed: • Fire safety records we looked at showed there were areas which required improvement."

Positive

"• There was a system for recording and acting on significant events and incidents but improvements were needed to ensure patient safety was maintained."

Positive

"With particular regard to fire safety and used of sites designated as ‘hot’ sites for service users who were potentially infectious."

Positive

"The service learned from external safety events and patient safety alerts."

Positive

"All staff were aware of the policy and understood their role with regards to it including ensuring that patient safety was a priority."

Positive

"• Service performance was not consistently monitored in a way that ensured patient safety at all times."

Positive

"• Staff received safety information from the provider as part of their induction and refresher training."

Positive

"Records showed that all relevant safety checks such as calibration of equipment and portable appliance testing had been undertaken."

Positive

"The risk assessments covered areas such as fire safety safe storage of medicines and safe storage of medical gas cylinders such as oxygen."

Positive

"After the inspection the provider informed us that locality managers were responsible for fire safety at bases."

Positive

"• The provider conducted safety risk assessments."

Positive

"It had safety policies including Control of Substances Hazardous to Health COSHH and Health & Safety policies which were reviewed and communicated to staff."

Positive

"Improvements were needed to maintain safety at all times."

Positive

"• The service had a system that alerted staff to any specific safety or clinical needs of a person using the service."

Neutral

"• There was limited measurement and monitoring of safety performance."

Neutral

"Track record on safety There were risk assessments in relation to safety issues however these were not consistent."

Neutral

"Managing risks issues and performance • The service monitored and reviewed activity but did not use the information effectively to understand risks to give a clear accurate and current picture that led to safety improvements."

Positive

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

Positive

"Safety systems and processes The service had systems to keep people safe and safeguarded from abuse but improvements were needed to ensure they were effective and consistent."

Neutral

"• There were systems and processes for managing infection control at the premises used to provide regulated activities however some audits had not been carried out due to a staff absence."

Neutral

"The policy set out that all staff should receive training on infection control processes on induction and then annually."

Neutral

"For example all staff should have received infection control training but this had not been completed."

Neutral

"This included infection control and safeguarding adults and children."

Positive

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

Positive

"Privacy and dignity The service did not consistently respect and promote patients’ privacy and dignity."

Positive

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

Positive

"Staff treated patients with compassion however there were shortfalls in making sure that call backs were carried out in a timely manner and patients were fully involved in decision making."

Positive

"In particular: • There were delays in responding to and investigating complaints and there was a lack of clarity on when a complaint should also be treated as a significant incident."

Positive

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

Positive

"The complaint policy and procedures informed complainants of the process that would be followed."

Positive

"• There was a lack of clarity on how an incident was categorised for the level of harm to a patient and whether a complaint should also be determined as a significant event."

Positive

"Our findings from this review was consistent with interviews with staff who indicated that whilst improved and better focused governance structures had been established it was early in the process of implementing improvement plans and there was significant work to be completed."

Positive

"This was with consent from the provider and in line with all data protection and information governance requirements."

Positive

"One of the conditions imposed on the provider’s registration included the need to implement and maintain sufficient oversight of governance process across the service."

Positive

"The service also considered that asking for help from external organisations such as clinical commissioning groups had assisted in starting to close the gap between governance and operations teams."

Positive

"These covered governance systems; privacy breaches; health and safety in the service; medicine management; infection control; complaints handling; recruitment process; consent to care and treatment; and staff training."

Positive

"Supporting staff also include communication and information governance staff."

Positive

"Conditions which related to the provision of the Out of Hours OOH service related to shortfalls in oversight of governance systems."

Neutral

"Staff employed by Devon Doctors Limited include; call handlers drivers reception staff GPs nurse practitioners call centre coordinators and supporting office staff holding lead roles such as clinical governance recruitment rotas and medicines."

Positive

"The arrangements for governance and performance management were not fully clear and did not operate effectively."

Positive

"• We reviewed the provider’s information governance policy and found that information contained within the policy referenced when staff should consider the need to report data protection breaches to the Information Commissioners Officer."

Positive

"These conditions were imposed as there were significant shortfalls in systems which led to delays to care and treatment; call answering targets were not consistently being met; there were often adequate numbers of staff; and governance processes were not effective."

Positive

"Supporting staff also include communication and information governance staff."

Positive

"Governance arrangements • A member of the leadership team told how the clinical commissioning groups CCG who commissioned the service were not always assured around the governance processes that were operating."

Positive

"• Quality and sustainability were discussed in relevant meetings but not all staff had sufficient access to information in relation to improvements that were needed."

Positive

"• The service did not have a comprehensive programme of quality improvement activity and did not routinely review the effectiveness and appropriateness of the care provided."

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

"Information from complaints was not consistently used to improve the quality of care provided."

Positive

"This was with consent from the provider and in line with all data protection and information governance requirements."

Positive

"• We reviewed the provider’s information governance policy and found that information contained within the policy referenced when staff should consider the need to report data protection breaches to the Information Commissioners Officer."

Positive

"A member of staff informed us that they would share examples with another GP practice which did not provide a direct comparator; undertake a review with another data protection officer from another organisation and with one of the CCGs; and share strategic learning through an Information Governance Network."