What is the Quality of Safety at Kingswood Surgery

Positive

"• Implement a process to ensure that all safety incidents are recorded investigated formally by the appropriate person monitor incidents for trends and share learning and lessons learnt with the practice staff."

Positive

"• Implement the remaining actions identified in the risk assessment relating to fire safety including staff training and fire drills."

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

Positive

"We saw evidence that practice learning had been shared with the hospital team and action was taken to improve 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 a legionella assessment."

Positive

"• National patient safety and medicine alerts were disseminated within the practice in a formal way which included the inhouse pharmacist and there was a system to record that these had been appropriately dealt with."

Positive

"During the inspection we saw that the health and safety policy displayed did not reflect the current health and safety arrangements this included incorrect contact details of the local health and safety representatives."

Positive

"For example monitoring of specific areas required improvement such as: • Significant event documentation fire safety uptake of some national screening programmes telephone access lack of an appraisal programme poor patient feedback and an inactive patient participation group."

Positive

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

Positive

"The clinical pharmacist worked alongside the GPs to ensure patient safety alerts including Medicines and Healthcare products Regulatory Agency MHRA alerts were reviewed and actioned."

Positive

"The practice had systems in place for knowing about notifiable safety incidents."

Neutral

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

Positive

"For example: • Patients receiving end of life care carers those at risk of developing a longterm condition and those requiring advice on their diet alcohol cessation received support or were signposted to the relevant service."

Positive

"The new practice manager was already aware of this and was reviewing the information available including signage within the practice to ensure it was suitable for all patients and was appropriate for the ethnic diversity within the practice."

Positive

"Clear signage throughout the practice identified the location of the emergency medicines and emergency equipment all staff knew of their location and all the medicines we checked were in date and stored securely."

Neutral

"The practice had implemented various systems including additional signage to reduce this from happening."

Positive

"However there was a lack of clinical leadership and governance framework to support the delivery of good quality care."

Positive

"At the start of the inspection the practice advised several areas and governance arrangements required a review and improvement."

Positive

"At the start of the inspection the practice advised us that several areas including governance arrangements required review and improvement."

Positive

"• The practice had a lack of good governance and the number of concerns we identified during the inspection demonstrated this."

Positive

"Governance arrangements The practice had a lack of good governance and the number of concerns we identified during the inspection demonstrated this."

Neutral

"• From the training log staff files and following discussions with staff we saw staff received training that included: safeguarding fire procedures basic life support and information governance awareness."

Positive

"• We saw limited evidence of quality improvement including clinical audit."

Positive

"During the inspection we saw limited evidence of quality improvement including clinical audit."

Positive

"• There was limited evidence of a programme of quality improvement including clinical audit."

Positive

"Verbal feedback aligned to comment cards praising the quality of care but reporting telephone access as a concern."

Positive

"Further patients comments said urgent and online appointments were always available and once an appointment was made the quality of care was excellent."

Positive

"This report describes our judgement of the quality of care at this service."

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."

Neutral

"One of the practice nurses had been appointed as the infection control lead."

Neutral

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

Neutral

"Annual infection control audits were undertaken."

Neutral

"We reviewed staff files and saw that there were records of some training in areas such as hand hygiene and infection control medical emergencies and safeguarding adults and children."

Positive

"f Evaluate and improve their practice in respect of the processing of the information referred to in subparagraphs a to e. • The provider had not ensured systems and processes were operated effectively to ensure good governance."

Positive

"• We observed members of staff were courteous and very helpful to patients and treated them with dignity and respect."

Positive

"Patients comments highlighted they felt the staff were helpful caring and treated them with dignity and respect."

Positive

"They told us the practice was responsive to patients needs including complex medicine needs and treated them with dignity and respect."

Positive

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

Positive

"Several comments we received referred to the tolerance and compassion from reception staff despite occasions when the increase in demand resulted in challenging situations."

Positive

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