What is the Quality of Facilities at Hawthorn Drive Surgery

Positive

"Any contact made by the parents or carers of young children vulnerable patients elderly patients and those with palliative care needs were highlighted to the duty GP to ensure this group of patients were dealt with swiftly."

Positive

"The practice was working with the CCG in relation to their high prescribing for patients with palliative care needs."

Neutral

"Appointment requests for children vulnerable patients the elderly and those with palliative care needs were prioritised."

Neutral

"• Appointment requests for children vulnerable patients the elderly and those with palliative care needs were prioritised."

Positive

"Any contact made by the parents or carers of young children vulnerable patients elderly patients and those with palliative care needs were highlighted to the duty GP to ensure this group of patients were dealt with swiftly."

Positive

"They had prioritised access to the clinicians for some patient groups including children the elderly and those with palliative care needs."

Positive

"Multidisciplinary meetings took place on a quarterly basis to discuss for example patients with complex needs those where there was a safeguarding need and those with palliative care needs."

Neutral

"• The practice told us that multidisciplinary meeting were held to discuss and review vulnerable patients the elderly children with safeguarding needs and patients with palliative care needs."

Neutral

"Appointment requests for children vulnerable patients the elderly and those with palliative care needs were prioritised."

Positive

"A Specialist Diabetes nurse attended one day a week to support patients with more complex diabetes needs."

Neutral

"There is one • nurse practitioners an emergency care practitioner a pharmacist a mental health practitioner two nurses and two healthcare assistants."

Positive

"The practice worked closely with a learning disability nurse to review patients on the learning disability register and had removed those who did not have a learning disability."

Positive

"The practice nurse had undertaken health checks at the patient’s home when this was appropriate and in the patient’s best interest."

Positive

"• The practice worked closely with a learning disability nurse and annual health assessments for people with a learning disability were undertaken by the practice nurse."

Positive

"• Formally review the work undertaken by advanced nurse practitioners to obtain assurance of the quality of their work."

Positive

"The advanced nurse practitioners received support from GPs."

Positive

"The practice nurse was the infection control clinical lead who liaised with the local infection prevention teams 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

"• A system of recall for patients who required monitoring had been established which included the implementation of a lead GP nurse and administration support."

Positive

"• GPs and the nurse practitioner undertook weekly visits to three nursing care homes to assess monitor and review a large number of patients who were residents."

Positive

"There are two advanced nurse practitioners two nurses and two healthcare assistants."

Positive

"We reviewed six recent consultations undertaken by an advanced nurse practitioner and did not identify any concerns regarding the consultation."

Positive

"• The practice had worked with a learning disability nurse and reviewed their patient register to ensure that patients were appropriately coded."

Neutral

"This was provided through elearning and face to face training by the infection control nurse and sharing of information in the staff newsletter."

Neutral

"We noted that there was no formal review by a GP of the work undertaken by the advanced nurse practitioners."

Neutral

"The different clinical areas of QOF also had an identified GP lead deputy GP lead nurse and administration lead."

Positive

"The practice had identified a GP nurse and administration lead for each area of the Quality and Outcomes framework QOF is a system intended to improve the quality of general practice and reward good practice."

Positive

"The practice had also identified a GP nurse and administration lead for each area of the Quality and Outcomes framework QOF is a system intended to improve the quality of general practice and reward good practice."

Positive

"• A system of recall for patients who required monitoring had been established which include a lead GP nurse and administration support and was due to be implemented imminently."

Positive

"There are two advanced nurse practitioners two nurses and three healthcare assistants."

Positive

"The practice nurse was the infection control clinical lead They liaised with the local infection prevention teams 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 are two advanced nurse practitioners two nurses and three healthcare assistants."

Neutral

"Staff told us the practice held reception meetings and nurse meetings but the management team mostly had informal conversations."

Positive

"A system of recall for patients who required monitoring had been embedded which included the implementation of a lead GP other clinical staff and administration support."

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."

Positive

"However there was no effective system in place for the monitoring of the completion of training and we found several staff had not completed training in safeguarding adults and children basic life support infection control and fire safety."

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

"This included the monitoring of infection control patients safety alerts National Institute for Health and Care Excellence NICE evidence based guidelines sharing of clinical audit findings significant events and complaints at the monthly clinical meeting."

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

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

Positive

"• A system of recall for patients who required monitoring had been established which included the implementation of a lead GP nurse and administration support."

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

"• Arrangements were in place for planning and monitoring the number of staff and mix of staff needed to meet patients’ needs."

Neutral

"The practice had reviewed the responses and had decided not to make any changes; however they planned to undertake this every month in order to review current patient feedback and make changes in response to this through monitoring satisfaction."

Positive

"Management monitoring and improving outcomes for people A data management team had been established to support the necessary improvements in relation to patient coding."

Positive

"• A system of recall for patients who required monitoring had been established which include a lead GP nurse and administration support and was due to be implemented imminently."

Positive

"• Governance arrangements were insufficient in relation to patient safety alerts significant events and complaints accurate coding and subsequent monitoring of patients."

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

"The practice had established a system for the recall of patients who required monitoring according to the month of their birthday."

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

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

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

"• Arrangements were in place for planning and monitoring the number of staff and mix of staff needed to meet patients’ needs."

Positive

"• Practice leaders had established policies procedures and activities to ensure safety however these were not always followed in practice."

Positive

"This included information on alcohol and drug support domestic abuse bereavement cancer carers homelessness mental health and wellbeing parenting social activities and sexual health."

Positive

"This included information on alcohol and drug support domestic abuse bereavement cancer carers homelessness mental health and wellbeing parenting social activities and sexual health."

Positive

"The areas where the provider should make improvements are: • Review and improve systems for managing infection prevention and control particularly the management of sharps boxes and the documentation of in house cleaning."

Neutral

"• Arrangements were in place for infection prevention and control however the checks of daily cleaning completed by clinical staff were not always completed."

Neutral

"• There was a system to manage infection prevention and control however the checks of daily cleaning completed by clinical staff were not always completed."

Neutral

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

Positive

"There was evidence of clinical audit with some two cycle audits which had a positive impact on the quality of care for patients."

Positive

"This included the monitoring of infection control patients safety alerts National Institute for Health and Care Excellence NICE evidence based guidelines sharing of clinical audit findings significant events and complaints at the monthly clinical meeting."

Positive

"There was no evidence of any completed clinical audit cycles."

Neutral

"This included one to one meetings appraisals mentoring clinical supervision and revalidation."

Positive

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

Positive

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

Positive

"GPs had a range of management and clinical leadership roles and other clinical and administration staff were identified to support with these lead roles."

Positive

"All the staff we spoke with reported positive changes in the clinical leadership of the GPs specifically highlighting that meetings were more structured and regular."

Positive

"Leadership and culture Although practice staff told us they felt supported by the GPs some staff reflected that they would benefit from more clinical leadership and guidance."

Positive

"• Although practice staff told us they felt supported by the GPs some staff reflected that they would benefit from more clinical leadership and guidance."

Positive

"• Ensure there is clinical leadership capacity to deliver all improvements."

Positive

"However some areas of infection control were not always completed for example the documentation of in house cleaning and the effective management of sharps."

Positive

"• The safe management of sharps boxes and the documentation of in house cleaning was not always undertaken."

Neutral

"• Arrangements were in place for infection prevention and control however the checks of daily cleaning completed by clinical staff were not always completed."

Neutral

"• There was a system to manage infection prevention and control however the checks of daily cleaning completed by clinical staff were not always completed."

Positive

"• Arrangements were in place to ensure the safe cleaning of spilt body fluids by staff with Hepatitis B immunity."

Positive

"Monthly cleaning audits were undertaken by the practice and although areas for action were identified on the audit the provider was in communication with the cleaning contractor to improve the cleanliness of the practice."

Positive

"Daily cleaning of clinical rooms was completed; however this was not consistently documented by the staff that were responsible for cleaning their own rooms."

Positive

"Safe practices were in place in relation to the cleaning of spilt body fluids."

Neutral

"The practice had engaged with staff to identify those who were willing to undertake cleaning of spilt body fluids."

Positive

"Nonclinical staff were responsible for cleaning spilt body fluids when their Hepatitis B immunity was not known and not all staff had received infection control training."

Positive

"• Ensure that internal audits of the cleaning are undertaken."

Positive

"There were no audits of the cleaning undertaken by the practice."

Neutral

"We saw evidence of staff cleaning checks by those staff employed by the practice."

Neutral

"We were told that records of cleaning were kept by the external cleaning company."

Neutral

"They also audited their own cleaning and sent reports to the practice."

Neutral

"The practice had guidance in place for cleaning up body fluids."

Neutral

"The Hepatitis B status of non clinical staff was not known and as nonclinical staff were responsible for cleaning spilt body fluids this constituted a potential risk to both staff and patients."

Positive

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

Positive

"These were limited to patient coding and medicine issues."

Neutral

"Patient Specific Directions are written instructions from a qualified and registered prescriber for a medicine which includes the dose route and frequency or appliance to be supplied or administered to a named patient after the prescriber has assessed the patient on an individual basis."

Positive

"Records showed medicine refrigerator temperature checks were carried out to ensure medicines and vaccines requiring refrigeration were stored at appropriate temperatures."

Neutral

"Patient Specific Directions are written instructions from a qualified and registered prescriber for a medicine which includes the dose route and frequency or appliance to be supplied or administered to a named patient after the prescriber has assessed the patient on an individual basis."

Positive

"However we checked the file of one receptionist who chaperoned and there was no DBS check in their file."

Positive

"Different areas of work for example multi disciplinary working information governance and health and safety also had an identified clinical lead identified team members with responsibility meetings when the subject was discussed and who the minutes were to be shared with."

Positive

"There was a GP lead for health and safety and a health and safety policy was available with a poster in the staff room."

Positive

"• Risks to patients and staff were assessed and well managed including those related to health and safety and infection control."

Neutral

"This covered areas such as safeguarding infection control fire safety dealing with emergencies health and safety and confidentiality."

Positive

"There was a lack of management oversight and coordination of the actions to be implemented in relation to significant events complaints patient safety alerts NICE guidance health and safety risk assessments and legionella risk assessments."

Positive

"There was a GP lead for health and safety and a health and safety policy was available with a poster in the staff room."

Neutral

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

Positive

"Any contact made by the parents or carers of young children vulnerable patients elderly patients and those with palliative care needs were highlighted to the duty GP to ensure this group of patients were dealt with swiftly."

Neutral

"Appointment requests for children vulnerable patients the elderly and those with palliative care needs were prioritised."

Neutral

"• Appointment requests for children vulnerable patients the elderly and those with palliative care needs were prioritised."

Positive

"Any contact made by the parents or carers of young children vulnerable patients elderly patients and those with palliative care needs were highlighted to the duty GP to ensure this group of patients were dealt with swiftly."

Positive

"They had prioritised access to the clinicians for some patient groups including children the elderly and those with palliative care needs."

Neutral

"• The practice told us that multidisciplinary meeting were held to discuss and review vulnerable patients the elderly children with safeguarding needs and patients with palliative care needs."

Neutral

"Appointment requests for children vulnerable patients the elderly and those with palliative care needs were prioritised."

Positive

"We spoke to the proposed chair of the practice PPG who was keen to be involved in the PPG to give something back to the practice."