What is the Quality of Facilities at Pembridge Villas Surgery

Positive

"There are also district nurses health visitors counsellors a community psychiatric nurse and a care navigator attached to the practice."

Positive

"The practice manager told us that the recruitment of nursing staff had previously been a problem however an additional nurse and health care assistant had recently been employed to ensure consistency of nursing staff."

Positive

"For example the group had suggested that it was difficult for patients to access the nurse to receive their test results within the daily hourly time slot."

Neutral

"There was a designated nurse who led on child protection and all staff were aware of their responsibilities for safeguarding children."

Neutral

"A practice nurse had been appointed as the dedicated lead in safeguarding vulnerable adults and children."

Positive

"The walkin clinics provided good access for patients to see a GP or nurse and telephone consultations were available on request."

Positive

"During our inspection we spoke with patients the GPs practice manager assistant practice manager nurse phlebotomist health care assistant and reception staff."

Positive

"The practice had developed expertise in caring for homeless patients and received support from the community psychiatric nurse and consultant psychiatrists during multidisciplinary meetings."

Positive

"Our findings The practice received support from the community psychiatric nurse and consultant psychiatrists during multidisciplinary meetings."

Positive

"The phlebotomist led on general cleanliness and safety of the building and environment and a practice nurse focused on reducing the risk of healthcare acquired infections."

Positive

"The practice was in the process of recruiting an additional practice nurse to meet the demands for the service."

Positive

"The learning from a complaint received regarding a locum nurse was to ensure practice staff encouraged patients to provide feedback when they saw a locum member of staff."

Positive

"The practice also had a policy in place to ensure newly registered children attended an appointment with their parentguardian so that the nurse could check their immunisation status."

Neutral

"During our visit we spoke with a range of staff including the two GP Partners two salaried GPs practice manager assistant practice manager nurse phlebotomist and reception staff."

Neutral

"Safeguarding The practice lead for safeguarding was a practice nurse who was not working on the day of our inspection."

Neutral

"We reviewed recruitment records for two GPs one nurse and one receptionist."

Neutral

"The practice manager informed us that she met with the practice nurse on a weekly basis to monitor and reallocate the workload of the nurse vacancy."

Neutral

"We were shown notes based on these discussions and emails to the nurse detailing the decisions management had made."

Neutral

"We noted there was a locum nurse working at the practice at the time of our visit."

Neutral

"These drugs were checked by the nurse and we saw records to confirm this."

Neutral

"We saw the CHD clinic appointment bookings which were offered with a nurse and a GP."

Neutral

"The patient would see the nurse initially for monitoring and see the GP to discuss the results and treatment options."

Neutral

"A new phone system ensured that calls were directed to the nurse rather than reception."

Neutral

"We saw evidence of a timetable for a new nurse to shadow clinics and clinicians so that they understood how the practice operated."

Neutral

"Lifestyle was also discussed and if concerns were identified then the patient would be referred to the nurse for further consultation."

Neutral

"We saw clinic appointment bookings where patients initially saw the nurse for monitoring and then the GP to discuss the results and treatment options."

Positive

"Management monitoring and improving outcomes for people Information about people’s care and treatment and their outcomes was routinely collected and monitored and this information used to improve care."

Positive

"There was a system in place for the management of high risk medicines such as lithium methotrexate and other disease modifying drugs which included regular monitoring in accordance with national guidance."

Positive

"Learning and improvement from safety incidents The practice had a system in place for reporting recording and monitoring significant events incidents and accidents."

Positive

"Staff across the practice had key roles in monitoring and improving outcomes for patients."

Positive

"Action was taken to review the patients records to ensure they were summarised appropriately and the notes were marked with an alert of the drug and monitoring requirements."

Positive

"The practice had started planning for the ‘outofhospital services’ whereby additional services including ambulatory blood pressure monitoring phlebotomy care planning and spirometry were offered to patients within the GP practice environment."

Positive

"We reviewed examples of completed audits regarding lithium prescribing vitamin D prescribing and monitoring of patients on immunosuppressant drugs."

Positive

"The practice had a system in place for reporting recording and monitoring significant events incidents and accidents."

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

"Staff told us about the arrangements for planning and monitoring the number of staff and mix of staff needed to meet patients’ needs."

Neutral

"We reviewed an audit of the monitoring of patients on immunosuppressant drugs."

Positive

"Two of the salaried GPs were responsible for monitoring significant events and we saw evidence that staff reviewed the National Institute for Health and Care Excellence NICE guidance and discussed events in team meetings."

Positive

"Management monitoring and improving outcomes for people The practice held clinics for patients with long term conditions such as chronic obstructive pulmonary disease COPD diabetes and coronary heart disease CHD and followed National Institute for Health and Care Excellence NICE guidance for these groups of patients."

Positive

"The practice was effective in monitoring and improving outcomes for patients."

Positive

"Two of the salaried GPs were responsible for monitoring significant events and we saw evidence that staff reviewed and discussed events in team meetings."

Positive

"The practice was monitoring and improving the quality of service through its work with the Patient Representative Group PRG investigation of complaints and analysis of significant events."

Positive

"The GPs were able to describe the topics audited such as referral rates of patients monitoring of immunosuppressant drugs and vitamin D supplements in children aged one – four years."

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

"We saw evidence of an audit of the monitoring of immunosuppressant drugs."

Neutral

"The patient would see the nurse initially for monitoring and see the GP to discuss the results and treatment options."

Neutral

"An example of the action taken by the practice in the audit of the monitoring of immunosuppressant drugs included developing new template letters for patients so that there was an audit trail of advice given to the patient."

Neutral

"We saw clinic appointment bookings where patients initially saw the nurse for monitoring and then the GP to discuss the results and treatment options."

Positive

"The practice manager completed an annual review of all complaints and we reviewed the complaints register which provided a detailed analysis of each complaint and an audit trail of activities undertaken to resolve the complaint."

Neutral

"We saw there were cleaning schedules in place and cleaning records were kept."

Neutral

"The building and nonclinical equipment was cleaned each weekday evening by an external cleaning company."

Neutral

"We saw evidence of cleaning schedules stored within the cleaning cupboard and these stated the daily weekly monthly and quarterly requirements."

Neutral

"There was evidence of a spotcheck audit against these cleaning schedules however this was not dated or signed."

Neutral

"We saw evidence of a rota and cleaning schedule which had been completed for several weeks prior to the inspection."

Neutral

"We did not see evidence of an audit schedule for spot checking the cleanliness of the clinical equipment or consultation rooms to provide assurance that cleaning was completed satisfactorily."

Positive

"Clinical staff had close working relationships with district and palliative care nurses to discuss care planning for patients who required extra support."

Positive

"It had a palliative care register and had regular internal as well as multidisciplinary meetings to discuss the care and support needs of patients and their families."

Positive

"These meetings were attended by district nurses social workers counsellors health visitors community psychiatric nurses palliative care nurses and a care navigator to discuss care planning for these patients and we reviewed minutes to some of these meetings."

Positive

"The practice had a palliative care register and these patients received end of life care and further support in line with their needs."

Positive

"We saw evidence there was a system for sharing appropriate information for patients with complex needs such as those in receipt of palliative care with the outofhours services."

Neutral

"For example to identify patients who were housebound receiving palliative care or patients with learning disabilities."

Neutral

"The practice held monthly multidisciplinary meetings with the community matron social workers and colleagues from local palliative care services to discuss the most vulnerable patients."

Positive

"For example there was a handrail and a ramp at the entrance an electronic push button for the front door and a stair lift Are services responsive to people’s needs?"

Neutral

"A stair lift had been installed between different levels on the ground floor providing access to clinical rooms on this level including a minor surgery room."

Positive

"The practice had a palliative care register and these patients received end of life care and further support in line with their needs."

Positive

"For example those with multiple long term conditions mental health problems people from vulnerable groups those with end of life care needs or children on the at risk register."

Positive

"The health and safety lead carried out annual fire risk assessments that included actions required to maintain fire safety."

Positive

"Health and safety information was displayed for staff to see and there was an identified health and safety lead."

Positive

"The practice also had a health and safety policy."

Positive

"Followup actions were recorded and updated by the health and safety lead."

Neutral

"We looked at a number of these policies and procedures including those relating to safeguarding infection control health and safety fire safety consent complaints and business continuity."

Positive

"Governance arrangements Staff roles and responsibilities were clear as the practice had identified leads for different areas such as infection control health and safety safeguarding significant events and information governance."

Positive

"Identification and management of risk The practice had systems in place to identify risk such as health and safety assessments and a business continuity plan."

Positive

"The practice lead for health and safety had received training in ‘health and safety assessment and management’."

Positive

"The practice had systems in place to identify risk such as health and safety assessments and a business continuity plan."

Positive

"Some staff had not received training in infection prevention and control and protecting vulnerable adults from the risk of abuse."

Neutral

"The practice assessed and monitored risks relating to the environment and staff followed appropriate infection prevention and control practices."

Positive

"We viewed the practice’s recent infection prevention and control audit which highlighted actions to be taken to resolve any issues."

Neutral

"Cleanliness and infection control The practice had identified two members of staff who led on cleanliness and infection prevention and control IPC."

Positive

"Medicines management We checked medicines stored in the treatment rooms and medicine refrigerators and found they were stored securely and were only accessible to authorised staff."

Neutral

"For example the GPs and nurses were advised to use a generic combined oral contraception medicine as an alternative to a branded version."

Positive

"One medicine kept with the emergency drugs in one of the nurse’s rooms would not be needed in an urgent situation and the practice should consider the risks of keeping it in unlocked storage."

Neutral

"Staff demonstrated awareness of how to respond in a medical emergency and regular checks of resuscitation drugs were undertaken to ensure they were fit for purpose."

Neutral

"Home visits were offered to patients who could not attend the practice and one patient told us that the GP spoke with her elderly father over the telephone and visited her father the same day."

Neutral

"The practice conducted a drug dependency clinic and received multidisciplinary input."

Neutral

"Prescribing for opioid dependency was undertaken via a multidisciplinary service and alerts were added to patient records so that physical health checks were undertaken when the patient attended the practice."