What is the Quality of Safety at The Beaches Medical Centre

Positive

"• We found the practice’s system for managing patient and drug safety alerts was not effective."

Neutral

"However we identified several new areas of concern and have rated the practice as inadequate for providing safe services because: • We found the practice’s system for managing patient and drug safety alerts did not ensure medicines were prescribed safely."

Neutral

"• We found a lack of governance structures and systems which led to significant patient safety concerns identified at this inspection."

Neutral

"In particular: • We found a lack of governance and assurance structures and systems which led to significant patient safety concerns identified at this inspection."

Positive

"This included improvements to the Quality and Outcomes Framework data completion of training deemed mandatory embedding the process for checking indemnity cover of clinicians and the oversight of safety systems including the timely completion of risk assessments and the consideration and completion of recommendations from risk assessments."

Positive

"The registered person had systems or processes in place that operated ineffectively in that they failed to enable the registered person to assess monitor and improve the quality and safety of the services being provided."

Positive

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

Positive

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

Positive

"• There was no effective system in place to deal with patient safety alerts."

Positive

"• There were no health and safety risk assessments in place."

Positive

"• There was a lead GP and lead administrative staff member who had responsibility for actioning patient safety alerts."

Positive

"The practice learned from external safety events as well as patient and medicine safety alerts."

Positive

"• Practice leaders had established proper policies procedures and activities to ensure safety and assured themselves that they were operating as intended or working towards that for example in relation to QOF."

Positive

"Actions from the health and safety risk assessment were monitored although not all actions had been completed."

Positive

"The areas where the provider should make improvements are: • Continue to action the recommendations from the health and safety risk assessment."

Positive

"• The practice conducted safety risk assessments."

Positive

"It had safety policies which were regularly reviewed and communicated to staff."

Positive

"Staff received safety information for the practice as part of their induction and refresher training."

Positive

"• Health and safety was a standing agenda item at practice meetings."

Neutral

"We looked at three safety alerts and reviewed patient records affected by these."

Neutral

"This helped it to understand risks and gave a clear accurate and current picture that led to safety improvements."

Positive

"In addition the provider should: • The provider should continue to monitor the newly implemented systems and processes to ensure improvements to quality and safety are made and monitored."

Positive

"• There was a lead GP and lead administrative staff member who had responsibility for actioning patient safety alerts."

Positive

"• There was no effective system in place to deal with patient safety alerts."

Positive

"Patient safety alerts were logged shared initial necessary searches were completed and the changes effected."

Positive

"• Reviewed practice documentation in relation to medicines which require monitoring safety alerts which included Medicines & Healthcare products Regulatory Agency MHRA alerts and the system for clinical coding."

Positive

"• The practice had a spreadsheet to record all parts of the process of managing safety alerts."

Positive

"We saw that patient safety alerts were shared with relevant staff and these staff members signed to say they had received and actioned the alert."

Positive

"Overview of safety systems and processes • The practice had implemented a new policy for the management of patients on medicines that require monitoring."

Neutral

"We looked at three safety alerts and reviewed patient records affected by these."

Neutral

"• We found that patients affected by safety alerts we viewed were being reviewed."

Positive

"• The practice had some risk assessments 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

"• From the sample of documented examples we reviewed we found there was a system for reporting and recording significant events; lessons were shared to make sure action was taken to improve safety in the practice."

Positive

"For example there was no health and safety risk assessment in place and no evidence of regular fire drills."

Positive

"There was no health and safety risk assessment in place and regular fire drills had not been undertaken."

Positive

"• We saw evidence that lessons were shared and action was taken to improve safety in the practice."

Positive

"• The risk assessment for the gym was not effective and did not ensure the safety of patients and staff."

Positive

"• The system in place to deal with patient safety alerts needed to be improved."

Positive

"• There was not an effective system in place to deal with patient safety alerts."

Positive

"We reviewed safety records incident reports patient safety alerts and minutes of meetings where significant events were discussed."

Positive

"There was not an effective system in place to deal with patient safety alerts."

Positive

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

Positive

"For example: • There was no health and safety risk assessment in place."

Positive

"There was also limited oversight of the safety arrangements by management in the practice for areas including patient safety alerts and risk assessments."

Positive

"In particular: • There was no health and safety risk assessment in place."

Positive

"• Arrangements to monitor and improve quality and identify risk were ineffective and did not assure the safety of patients and staff."

Positive

"The arrangements for managing medicines including emergency medicines and vaccines in the practice needed improving to reduce risks to patient safety including obtaining prescribing recording handling storing security and disposal."

Positive

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

Positive

"• There was an ineffective system for dealing with patient safety alerts."

Neutral

"We looked at a three safety alerts and reviewed patient records affected by these."

Neutral

"Overview of safety systems and processes The practice had some systems processes and practices in place to minimise risks to patient safety."

Neutral

"• There was no health and safety risk assessment completed to ensure that patients and staff were kept safe."

Neutral

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

Positive

"Monitoring safety and responding to risk There was a proactive approach to anticipating potential safety risks including changes in demand disruption to staffing or facilities or periodic incidents such as bad weather or illness."

Positive

"This ensured that matters that may have an impact on patient care and safety were discussed to ensure awareness and effective service delivery."

Positive

"All staff were fully trained on the system and commented positively about the system’s safety and ease of use."

Positive

"The practice manager showed us their risk log which addressed a wide range of potential issues such as health and safety and fire risk assessments legionella and infection control."

Positive

"Learning and improvement from safety incidents The practice had a system in place for reporting recording and monitoring significant events incidents and accidents."

Positive

"We saw the staff training record which showed that staff were up to date with mandatory training including basic life support infection control fire safety and safeguarding of vulnerable adults and children."

Positive

"For example reported incidents national patient safety alerts as well as comments and complaints received from patients."

Positive

"We reviewed safety records and incident reports and saw minutes of meetings where these were discussed for the last year."

Positive

"National patient safety alerts were disseminated by the practice manager to practice staff."

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 manager told us that safety checks with the Disclosure and Barring Service DBS for clinical staff had been performed."

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."

Neutral

"For example some nurses had attended cytology and phlebotomy training and a healthcare assistant had completed training in nutrition and health and smoking cessation."

Neutral

"We noted the team went for meals and held charity events."

Neutral

"• Staff through staff meetings heads of departments and team building events such as meals and charity days."

Positive

"A number of recommendations had been completed for example fire alarms were tested regularly and this was documented and fire exit signage was in place."

Positive

"The practice provided facilities to help patients be involved in decisions about their care: • Staff told us that interpretation services were available for patients who did not have English as a first language as well as sign language services for patients that were deaf."

Neutral

"The sign in screen was available in different languages."

Positive

"These included an action plan to encourage patients to notify the practice of their change of contact details and improved signage for the nursing area of the practice."

Positive

"For example improved signage for the nursing department and improvements to the practice telephone system."

Neutral

"The practice also had a hearing loop and some staff had attended a basic sign language course to assist patients with hearing impairments."

Positive

"The practice was rated as good for providing caring services because: • Staff treated patients with kindness respect and compassion."

Positive

"We rated the practice as good for providing caring services because: • Staff dealt with patients with kindness and respect and involved them in decisions about their care."

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 national GP patient survey information we reviewed showed that patients did not always report that they were treated with compassion dignity and respect or that they were involved in decisions about their care and treatment."

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

"• The national GP patient survey information we reviewed showed that patients did not always report that they were treated with compassion dignity and respect or that they were involved in decisions about their care and treatment."

Positive

"They told us they were satisfied with the caring nature of clinical staff provided by the practice and said their dignity and privacy was respected; however we received additional negative comments relating to getting through to the surgery by telephone and appointments not running to time."

Positive

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

Positive

"Our key findings were as follows: • Patients were satisfied with the service and felt they were treated with dignity care and respect and involved in their care."

Positive

"The evidence from this showed patients were satisfied with how they were treated and that this was with compassion dignity and respect."

Positive

"Patients told us they felt the staff respected their privacy and dignity and the GPs were very approachable and supportive."

Positive

"Patients told us they were treated with dignity and respect by both nonclinical and clinical staff."

Positive

"There were systems in place to support patients and those close to them to receive emotional support from suitably trained staff when required particularly near the end of a person’s life and during bereavement."

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."

Neutral

"• We found a lack of governance structures and systems which led to significant patient safety concerns identified at this inspection."

Neutral

"In particular: • We found a lack of governance and assurance structures and systems which led to significant patient safety concerns identified at this inspection."

Positive

"The areas where the provider must make improvements are: • Ensure 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 practice culture and governance arrangements did not effectively support high quality sustainable care; they did not have any identified values and staff felt under pressure due to staff sickness and uncertainty of the future."

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

"• Structures processes and systems to support good governance and management were clearly set out understood and effective."

Positive

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

Positive

"• A number of staff had lead roles for example for safeguarding information governance and complaints."

Positive

"• The practice had worked hard to develop an overarching governance system which gave the management team an overview of the performance of the practice."

Positive

"• The practice did not demonstrate overarching clinical or nonclinical governance or leadership."

Positive

"• The practice did not demonstrate overarching clinical or nonclinical governance or leadership."

Neutral

"• There was an overarching governance system in place which gave management an overview of the performance of the nursing team."

Positive

"Areas for improvement Action the service MUST take to improve • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care."

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

"The practice had a skill mix of clinicians to meet patient needs however did not yet have strong clinical governance to support this model of care."

Positive

"• The governance arrangement for the oversight of the clinical teams was not effective and did not ensure cohesive working."

Positive

"Governance arrangements We found that there was a lack of clinical and managerial governance which did not support the delivery of the strategy and good quality care."

Positive

"• There was not an effective overarching clinical or nonclinical governance or leadership system in place."

Neutral

"• The governance framework was not always effective and did not assure us that risks to patients were always mitigated."

Neutral

"Governance arrangements There were systems in place to manage governance of the practice."

Positive

"This inspection was carried out to review in detail the actions taken by the practice to improve the quality of care and to confirm whether the practice was now meeting legal requirements."

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

"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

"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

"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 recognises the significant improvements made to the quality of care provided by the 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

"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

"Arrangements had been agreed for additional support development and sustainability for the practice and partners."

Positive

"• Continue with the planned programme of quality improvement activity."

Positive

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

Positive

"• There was one full cycle audit that demonstrated quality improvement and five single cycle audits."

Positive

"There was evidence of some quality improvement including clinical audit: There had been six clinical audits commenced in the last two years one of these was a two cycle completed audit where the improvements made were implemented and monitored."

Positive

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

Positive

"They told us they were satisfied with the caring nature of clinical staff provided by the practice and said their dignity and privacy was respected; however we received additional negative comments relating to getting through to the surgery by telephone and appointments not running to time."

Positive

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

Positive

"Patients told us they felt the staff respected their privacy and dignity and the GPs were very approachable and supportive."

Positive

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

Positive

"• Staff we spoke with knew how to recognise signs of abuse in children young people and adults whose circumstances may make them vulnerable."

Neutral

"However there were examples of good practice: • Staff were able to recognise the signs of abuse in older patients and knew how to escalate any concerns."

Positive

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

Positive

"The infection control lead nurse completed monthly checks to ensure infection control measures were effective."

Neutral

"There was a lead for infection control who had received additional training and attended local meetings to keep updated."

Neutral

"Internal infection control audits were completed."

Positive

"• The practice had some risk assessments 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

"Cleanliness and infection control We observed the premises to be clean and tidy."

Positive

"We saw the staff training record which showed that staff were up to date with mandatory training including basic life support infection control fire safety and safeguarding of vulnerable adults and children."

Positive

"An infection control policy and supporting procedures were available for staff to refer to which enabled them to plan and implement control of infection measures."

Neutral

"The practice had a lead for infection control who 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 there after annual updates."

Neutral

"For example personal protective equipment including disposable gloves aprons and coverings were available for staff to use and staff were able to describe how they would use these in order to comply with the practice’s infection control policy."

Neutral

"For example there was a lead nurse for infection control and the senior partner was the lead for safeguarding."

Positive

"• The practice actively promoted equality and diversity and staff had received equality and diversity training."

Neutral

"All staff had received equality and diversity training."

Positive

"We reviewed a number of policies for example the induction policy and equality and diversity which were in place to support staff."

Neutral

"Tackling inequity and promoting equality The practice was accessible for any vulnerable group."

Neutral

"Staff we spoke with confirmed that they had completed the equality and diversity training and that equality and diversity was discussed at staff meetings."

Positive

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

Positive

"• Information about how to make a complaint or raise concerns was available and it was easy to do this."

Neutral

"For example one complaint reviewed did not include a written response to the patient but the practice told us they had spoken to the patient to resolve the issue."

Positive

"Information on how to raise a complaint or concern was clearly displayed within the practice in the practice leaflet and information was also available on the practice website."

Positive

"The review recorded the outcome of each complaint and identified where learning from the event had been shared with staff."

Neutral

"Staff told us that if someone wanted to make a complaint the receptionist would see if there was anything they could help with or patients could speak with or see the practice manager."

Positive

"• The practice provided a fully equipped gym to assist patients with their quality of life improvements."