What is the Quality of Safety at Freuchen Medical Centre

Positive

"• Provide facilities to meet the needs of mothers babies and those patients who are hard of hearing and provide privacy curtains in all consultation rooms."

Positive

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

Positive

"However there were no privacy curtains in the two nurses rooms."

Neutral

"In treatment and consulting rooms clinicians told us that privacy curtains and window blinds were used to preserve privacy for patients."

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 and smoking and alcohol cessation."

Positive

"Patients said they felt the practice offered an excellent service 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

"Results from the national GP patient survey showed patients felt they were treated with compassion dignity and respect."

Positive

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

Positive

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

Positive

"However the practice’s own annual survey and the national patient survey indicated that over the last three years patients had become less satisfied with the levels of respect consideration and concern shown by clinical and nonclinical staff at the practice."

Positive

"The practice’s own annual survey indicated that over the last three years patients had become less satisfied with the levels of respect consideration and concern shown by clinical and nonclinical staff."

Positive

"We saw evidence to show that the practice was performing well within the CCG area with respect to rate of antibiotic prescribing and percentage of ibuprofen and naproxen with respect to all nonsteroidal antiinflammatory drugs NSAIDs."

Positive

"Freuchen Medical Centre’s own annual survey indicated that over the last three years patients had become less satisfied with the levels of respect consideration and concern shown by clinical and nonclinical staff at the practice."

Positive

"We spoke with two members of the patient participation group PPG on the day of our visit and they told us they felt they were treated with dignity and respect."

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

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

Positive

"They were aware to potential risks to the quality of care they provided because of an increasingly diverse practice population in a highly deprived area."

Positive

"• There was an effective system in place for reporting and recording significant events • Lessons were shared to make sure 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 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 • The practice proactively sought feedback from patients which it acted on."

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

"Our key findings across all the areas we inspected were as follows: • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events."

Positive

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

Positive

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

Positive

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

Positive

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

Positive

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

Positive

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

Positive

"Our key findings were as follows: • safe systems were in place to monitor and manage individual patient care and safety • care was planned and delivered effectively and patients underwent regular monitoring and medicines reviews • patients reported that they felt listened to and involved in decision making."

Positive

"Management monitoring and improving outcomes for people We saw that data sources medicines management information safety alerts or as a result of Quality and Outcomes Framework QOF performance were used to gather information about patient experience quality and performance."

Positive

"The practice had carried out a health and safety risk assessment which detailed risks to staff and patients such as slipping and tripping on cables or objects left on the floor and actions taken to minimise those risks."

Positive

"Fire Safety drills and checks of the alarm system and fire safety equipment were regularly carried out within the building."

Positive

"Learning and improvement from safety incidents We reviewed three SEA forms."

Positive

"The GP child safeguarding lead shared information with multidisciplinary teams to improve the safety of vulnerable children."

Positive

"We saw a gas safety certificate which showed that the heating system had been checked this year and was safe."

Positive

"Monitoring safety and responding to risk The practice monitored safety and responded to risk."

Positive

"The practice had systems in place to identify respond to and learn from patient safety issues."

Positive

"National patient safety alerts were disseminated to staff electronically by a designated staff member."

Positive

"Staff had roles and responsibilities that included taking a lead role in key areas in the practice such as safeguarding children and vulnerable adults infection prevention and control health and safety and areas of clinical expertise."

Neutral

"Reliable safety systems and processes including safeguarding Staff were able to recognise signs of abuse in older patients and knew how to escalate and refer those concerns."

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."

Positive

"Nonclinical staff were able to describe the different forms of abuse and how they would report a concern."

Positive

"There was a lead clinician responsible for safeguarding vulnerable adults and staff were able to recognise signs of abuse in older people and we were informed of incidences when these concerns had been escalated to the appropriate authorities."

Neutral

"Reliable safety systems and processes including safeguarding Staff were able to recognise signs of abuse in older patients and knew how to escalate and refer those concerns."

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 infection control and legionella Legionella is a term for a particular bacterium which can contaminate water systems in buildings."

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."

Neutral

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

Neutral

"Annual infection control audits were undertaken and we saw evidence that action was taken to address any improvements identified as a result."

Positive

"A cleaner who had received infection control training attended every working day and followed a cleaning schedule which included daily weekly and monthly tasks."

Positive

"However no infection control audits had been carried out to check that procedures were being followed to prevent and protect people from a healthcareassociated infection."

Neutral

"Cleanliness and infection control The practice had an infection control policy which included contact details of the community infection control team."

Neutral

"All staff members we spoke to were aware of the policy and that the lead on infection control was the practice nurse."

Neutral

"We checked staff files and found that staff had received or were booked to undertake updated infection control training."

Neutral

"Training records for staff showed they had completed training in areas such as safeguarding children and adults infection control and equality and diversity."

Positive

"The practice apologised to the patient and the complaint discussed in a meeting and learning shared within the clinical team."

Positive

"The complaints process was referred to in the practice leaflet although it was not clear who the patient should contact in the first instance to make a complaint as the designated person was different to that in the complaints policy."

Positive

"The practice manager said they or a doctor would try to speak to the patient making the complaint initially if that was appropriate to see if they could resolve the matter promptly."

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."

Neutral

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

Positive

"Governance arrangements There was a governance lead GP and when we asked practice staff about governance arrangements they were clear about who was responsible for each area."

Positive

"There was a governance lead and clinical and nonclinical staff were clear on their roles and responsibilities in key areas such as safeguarding and infection control."

Positive

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

Positive

"Clinical staff worked with the health visitor and district nursing staff to provide coordination of care."

Neutral

"Training records for staff showed they had completed training in areas such as safeguarding children and adults infection control and equality and diversity."

Neutral

"Tackling inequity and promoting equality The service acted to remove barriers with patients who may find it difficult to access the service."