What is the Quality of Safety at Southgates and The Woottons Surgeries

Neutral

"• Staff provided patients with guidance on preoperative fasting for procedures requiring sedation and gave patients something to eat and drink after surgery if required."

Neutral

"Nutrition and hydration • Patients undergoing hernia repair were advised to fast for six hours before their operation but were allowed to drink water until two hours before their operation."

Positive

"Supporting patients to live healthier lives The practice identified patients who may be in need of extra support 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."

Positive

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

Positive

"Action the provider SHOULD take to improve • The provider should consider the physical environment of the recovery area to ensure that this maximises patient privacy and dignity."

Neutral

"Although the two areas were divided by a curtain this was not an ideal environment as it may have impacted on patient privacy during recovery."

Positive

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

Positive

"• The practice had a variety of other 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

"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

"Overview of safety systems and process 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

"• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events."

Positive

"• Where learning was identified this was shared with staff and action was taken to improve safety in the practice."

Positive

"• The practice had implemented systems and processes to identify and mitigate risks relating to fire safety and legionella."

Positive

"• The systems and processes in place to identify and mitigate risks relating to fire safety and legionella needed to be improved."

Positive

"• We reviewed patient safety alerts and minutes of meetings where these were discussed."

Positive

"• There was a health and safety policy available."

Positive

"• The practice staff received training that included safeguarding fire safety awareness and basic life support and information governance."

Positive

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

Neutral

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

Positive

"The duty of candour is a regulatory duty that relates to openness and transparency and requires providers of health and social care services to notify patients or other relevant persons of certain ‘notifiable safety incidents’ and provide reasonable support to that person."

Positive

"• The theatre manager was aware of National Safety Standards for Invasive Procedures NatSSIPs and had reviewed these standards to ensure that the surgical safety checks in place at the service were adequate."

Positive

"• Staff completed the World Health Organisation WHO surgical safety checklist and five steps to safer surgery for all patients."

Positive

"Never events are serious incidents that are entirely preventable as guidance or safety recommendations providing strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers."

Positive

"On our unannounced inspection we saw staff completing and documenting surgical safety checks appropriately."

Positive

"This meant that the equipment used could be traced effectively if any safety issues were identified."

Positive

"Staff completed safety checks on this equipment on days when surgery took place."

Positive

"This is a safety checklist used to reduce the number of complications and deaths from surgery."

Positive

"On our unannounced inspection we saw staff completing and documenting surgical safety checks."

Positive

"• We saw records for electrical safety testing of clinical equipment which showed that all equipment that was in use had been tested and passed the required checks."

Positive

"Mandatory training • Information provided by the service showed that both permanent theatre staff were up to date with mandatory training which included basic life support moving and handling and fire safety among others."

Positive

"These audits included handwashing infection control and fire safety audits."

Positive

"These assessments were comprehensive but the practice had failed to undertake all the actions identified in the risk assessments relating to fire safety and had not undertaken a risk assessment to identify and mitigate the risk associated with legionella disease."

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

"• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events."

Positive

"• Where learning was identified this was shared and action was taken to improve safety in the practice."

Positive

"• Ensure that systems and processes are in place to identify and mitigate risks relating to fire safety and legionella."

Positive

"There was a health and safety policy available with a poster in the office which identified local health and safety representatives."

Positive

"• The practice staff received training that included safeguarding fire safety awareness and basic life support and information governance."

Positive

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

Neutral

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

Positive

"Overview of safety systems and process 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

"• The practice had a variety of other 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

"A member of the nursing team was the infection control clinical lead and they liaised with the local infection prevention teams to keep up to date with best practice."

Neutral

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

Positive

"Cleanliness infection control and hygiene • All areas we inspected were visibly clean and tidy."

Positive

"These audits included handwashing infection control and fire safety audits."

Neutral

"• The provider had an infection control policy."

Positive

"An infection control clinical lead had been appointed and they liaised with the local infection prevention teams to keep up to date with best practice."

Neutral

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

Positive

"Surgeons were required to sign a consultancy agreement which included an obligation to maintain their competence and the general manager told us that surgeons’ competency would be monitored through audit of clinical outcomes."

Neutral

"We saw audit results displayed on the staff noticeboard which staff were required to sign to confirm they had read."

Positive

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

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 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 were listened to and were involved in decisions about their care and treatment."

Positive

"• We saw staff treat 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 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 were listened to and were involved in decisions about their care and treatment."

Positive

"• We saw staff treat 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

"Each complaint had been investigated and lessons were learnt."

Positive

"Senior managers had responded to the complaint with a letter of apology for any distress caused to the patient."

Positive

"• Information on how to make a complaint was available to patients."

Positive

"The complaint was under investigation at the time of our inspection."

Positive

"Each complaint had been fully detailed and lessons were learnt."

Positive

"• An overarching governance framework supported the delivery of the strategy and good quality care."

Positive

"They held regular governance meetings with comprehensive minutes taken to ensure that all actions were managed and reviewed."

Positive

"We found the following areas of good practice: • Staff had access to clinical and governance policies online and also in paper format."

Positive

"The general manager told us that any policies requiring review went to the nurses meeting or managers meeting for review by relevant members of staff and were then ratified at the clinical governance meeting."

Positive

"The general manager told us that policies were reviewed by relevant staff and were then ratified at the clinical governance meeting."

Positive

"• The general manager told us changes to policy were shared at clinical governance meetings which included representatives from the surgical unit and the GP practice."

Positive

"Clinical governance meeting minutes showed that updates to the risk register were recorded and shared with staff."

Neutral

"They advised that this issue would be discussed at the next clinical governance meeting."

Neutral

"The surgery unit was included in governance arrangements for the GP service which owned the unit ."

Neutral

"• Incidents were discussed at clinical governance meetings."

Neutral

"• Staff told us they discussed audit results at clinical governance meetings team meetings and management meetings."

Neutral

"Governance risk management and quality measurement • The surgery unit was included in governance arrangements for the GP practice which owned the unit."

Neutral

"Clinical governance meetings took place every six weeks and were attended by staff from the surgery unit and the GP practice."

Neutral

"Information from clinical governance meetings was passed on to staff verbally at team meetings and through the staff information board."

Neutral

"We saw that policy and procedure was a standing item on the agenda of clinical governance meetings."

Positive

"• An overarching governance framework 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; the newly formed management team recognised that some improvements needed to be made and they were working towards this."

Positive

"They held regular governance meetings with comprehensive minutes taken to ensure that all actions were managed and reviewed."

Positive

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

Positive

"Innovation improvement and sustainability • The theatre manager was focused on improving the quality of care through audit and feedback from patients and staff."

Positive

"• The theatre manager told us how they monitored the average list size of each consultant and liaised with consultants to ensure that the size of each theatre list was appropriate to maximise patient flow while also maintaining quality of care for patients ."

Positive

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

Positive

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

Positive

"However where patients did complain improvements were made to the quality of care as a result."

Positive

"Innovation improvement and sustainability • The theatre manager was focused on improving the quality of care through audit and feedback from patients and staff."