What is the Quality of Safety at Hawthorn Drive Surgery

Positive

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

Positive

"Patients said they were treated with dignity and respect and were involved in their care and decisions about their treatment • In general patients found the appointment system easy to use and reported that they could access care when they needed it."

Positive

"• The practices GP patient survey results were in line with local and national averages for questions relating to kindness respect and compassion."

Positive

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

Positive

"• Staff involved and treated patients with compassion and kindness."

Positive

"• Staff were clear on their roles and accountabilities including in respect of safeguarding."

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 discrimination and breaches of their dignity and respect."

Positive

"Kindness dignity respect and compassion We observed members of staff were polite and very helpful to patients and treated them with dignity and respect."

Positive

"We spoke with seven patients six of whom told us they were very satisfied with the care provided by the practice and staff were helpful caring and treated them with dignity and respect."

Positive

"• Patients said they were treated with compassion dignity and respect and they were involved in decisions about their care and treatment."

Positive

"• Patients said they were treated with dignity and respect and were involved in their care and decisions about their treatment."

Positive

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

Positive

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

Positive

"Patients told us they were very satisfied with the care provided by the practice and staff were helpful caring and treated them with dignity and respect."

Positive

"Patients said they felt the practice offered an excellent service and staff were helpful caring treated them with 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

"• Patients said they were treated with compassion dignity and respect and they were involved in decisions about their care and treatment."

Positive

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

Positive

"We spoke with representatives from three care homes who said they were satisfied with the service provided by the practice and had no concerns regarding dignity and privacy."

Positive

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

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

"Governance arrangements There were clear responsibilities roles and systems of accountability to support good governance and management however they were not always effective."

Positive

"• The governance and management of partnerships joint working arrangements and shared services promoted coordinated personcentred care."

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."

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

"• A foundation for effective governance had been established and maintained."

Neutral

"The practice had a number of policies and procedures to govern activity and held regular governance meetings."

Positive

"• Continue to embed the newly formed system of governance and ensure it is effective."

Positive

"A framework for effective governance had been established which needed to be embedded to ensure its efficacy."

Positive

"• A foundation for effective governance had been established."

Neutral

"• We reviewed meeting minutes policies and procedures and details of governance structures within the practice."

Positive

"Governance arrangements The practice governance framework which supported the delivery of the strategy and good quality care needed to be improved."

Positive

"• The practice did not have governance systems in place to ensure patients were identified and received timely safe care and treatment."

Positive

"For example governance arrangements were insufficient."

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

Positive

"• The practice considered and understood the impact on the quality of care of service changes or developments."

Positive

"The practice could not yet evidence a programme of completed audits that had been rerun to monitor and improve outcomes on the quality of care 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

"Improvements were made to the quality of care as a result of complaints and concerns."

Positive

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

Positive

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

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."

Positive

"The practice is rated as requires improvement for providing safe services because: • The practice was not able to evidence that all staff had completed appropriate training which included safeguarding children and vulnerable adults basic life support fire safety and infection control training."

Positive

"The practice learned and shared lessons identified themes and acted to improve safety in the practice."

Positive

"• An effective system was in place to review and act on safety alerts and this had been embedded."

Positive

"However on the day of the inspection the practice was not able to evidence that all staff had received uptodate safeguarding and safety training appropriate to their role."

Positive

"Track record on safety The practice track record on safety was mixed."

Positive

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

Positive

"We identified staff who had not completed basic life support safeguarding infection control and fire safety training and the practice had no effective system to identify this."

Positive

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

Positive

"Practice leaders had oversight of safety alerts incidents and complaints."

Positive

"• There were comprehensive risk assessments in relation to safety issues."

Positive

"• The practice monitored and reviewed safety using information from a range of sources."

Positive

"• There was an emphasis on the safety and wellbeing of all staff."

Positive

"The practice had other risk assessments in place to monitor the safety of the premises such as disability access 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

"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

"Overview of safety systems and processes The practice had 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

"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

"Learning was shared and 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

"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

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

Positive

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

Positive

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

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."

Positive

"• Health and safety risks to patients and staff were assessed and managed."

Neutral

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

Positive

"We saw that safety alerts information from audits and discussion and leaning from significant events and complaints was shared appropriately with staff."

Positive

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

Positive

"• The arrangements to ensure that patient safety alerts and agreed actions from significant events and complaints were actioned were not adequate."

Positive

"Areas for improvement Action the service MUST take to improve • Ensure there is an effective process for sharing and checking that actions have been completed in relation to patient safety alerts for example MHRA alerts and NICE guidance."

Positive

"The areas where the provider must make improvement are: • Ensure there is an effective process for sharing and checking that actions have been completed in relation to patient safety alerts for example MHRA alerts and NICE guidance."

Positive

"• There was an effective system in place for reporting and recording significant events but no formal process for sharing learning and ensuring that actions identified had been completed to make sure safety in the practice was improved."

Positive

"• Patient safety alerts were not logged shared and searches were not completed to ensure the changes were implemented."

Positive

"For example a recent safety alert regarding the importance of advising women to check the positioning of a contraceptive implant had not been shared with the clinicians who undertake this procedure."

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 Are services safe?"

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

"Overview of safety systems and processes The practice did not have clearly defined and embedded systems processes and practices in place to keep patients safe and safeguarded from abuse."

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 discrimination and breaches of their dignity and respect."

Positive

"Safety systems and processes The practice had systems to keep people safe and safeguarded from abuse however they were not always followed."

Positive

"Overview of safety systems and processes The practice had 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

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

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 practice is rated as requires improvement for providing safe services because: • The practice was not able to evidence that all staff had completed appropriate training which included safeguarding children and vulnerable adults basic life support fire safety and infection control training."

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

"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."

Positive

"We identified staff who had not completed basic life support safeguarding infection control and fire safety training and the practice had no effective system to identify this."

Positive

"This included training for safeguarding children and vulnerable adults basic life support infection control and fire safety."

Neutral

"Staff had not all completed infection control training."

Positive

"The practice had other risk assessments in place to monitor the safety of the premises such as disability access 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

"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

"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

"The lead for infection control and staff had received training for their role by elearning face to face training and by information shared in staff newsletters."

Neutral

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

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

"An annual infection control audit had been undertaken and we saw evidence that actions had been undertaken to address the improvements identified."

Neutral

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

Positive

"The practice were in the process of identifiying an infection control and prevention course and further support in relation to audits to enable the lead to undertake their role effectively."

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

"Nonclinical staff were expected to clean body fluids without their Hepatitis B immunity being checked and not all staff had completed infection control training."

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."

Neutral

"We looked at three staff files and one staff member had completed infection control eLearning."

Positive

"• The practice actively promoted equality and diversity."

Positive

"• Information about how to make a complaint or raise concerns was available both in the practice and on the practice’s website."

Positive

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

Positive

"For example one complaint resulted in a change to policy so all patients were now contacted by telephone or letter when their medicines were changed following advice from the hospital or by a clinician at the practice."

Positive

"• Quality and sustainability were discussed in relevant meetings where all staff had sufficient access to information."

Positive

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

Positive

"• Continue the current programme of quality improvement including clinical audits to monitor the effectiveness of new systems and processes."

Positive

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

Positive

"There was some evidence of quality improvement as the practice participated in local audits and national benchmarking."