What is the Quality of Safety at Pembridge Villas Surgery

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

"Patients said staff always treated them with dignity and respect and they felt supported in making decisions about their care and treatment."

Positive

"The evidence from these sources showed patients were satisfied with how they were treated and that this was with compassion dignity and respect."

Positive

"All told us they were satisfied with the care provided by the practice and said their dignity and privacy was respected by clinical and nonclinical staff."

Positive

"Patientcarer support to cope emotionally with care and treatment Patients were offered referral to emotional support services such as an inhouse counselling clinic a community mental health service and a drug and alcohol addiction service."

Positive

"We also saw that staff treated patients with kindness and respect and maintained confidentiality."

Positive

"None of the patients we spoke with on the day of our inspection or who completed the CQC comment cards mentioned emotional support or treatment however notices in the patient waiting room and on the practice website told patients how to access a number of support groups and organisations."

Positive

"They said staff treated them with dignity and respect."

Positive

"Patients were offered referral to emotional support services such as an inhouse counselling clinic a community mental health service and a drug and alcohol addiction service."

Positive

"The national patient survey showed that respondents rated the practice similar to or slightly above the CCG and national averages for the emotional support provided by the practice."

Positive

"Privacy screens were provided in consulting rooms so that patients’ privacy and dignity was maintained during examinations investigations and treatments."

Positive

"Staff told us that if they had any concerns or observed any instances of discriminatory behaviour or where patients’ privacy and dignity was not being respected they would raise these with the practice manager."

Positive

"Areas for improvement Action the service MUST take to improve The practice did not have privacy screens in most consulting rooms to respect patients’ privacy and dignity during consultations."

Positive

"The practice did not have privacy screens in most consultation rooms and curtains or blinds were not present in one consulting room to respect patients’ privacy and dignity during consultations."

Positive

"Our findings Respect dignity compassion and empathy We observed reception staff greeted patients in a polite and friendly manner."

Positive

"The practice provides good care but some areas of the service require improvement including respecting patients’ privacy and dignity during examinations."

Positive

"How the regulation was not being met: The registered person did not make suitable arrangements to ensure the dignity and privacy of service users."

Positive

"The practice did not always respect patients’ privacy and dignity."

Positive

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

Positive

"However lessons learned from individual complaints had been acted on and improvements made to the quality of care as a result."

Positive

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

Positive

"All told us they were satisfied with the care provided by the practice and said their dignity and privacy was respected by clinical and nonclinical staff."

Positive

"Privacy screens were provided in consulting rooms so that patients’ privacy and dignity was maintained during examinations investigations and treatments."

Positive

"Staff told us that if they had any concerns or observed any instances of discriminatory behaviour or where patients’ privacy and dignity was not being respected they would raise these with the practice manager."

Neutral

"Staff and patients told us that all consultations and treatments were carried out in the privacy of a consulting room."

Positive

"The practice provides good care but some areas of the service require improvement including respecting patients’ privacy and dignity during examinations."

Positive

"Areas for improvement Action the service MUST take to improve The practice did not have privacy screens in most consulting rooms to respect patients’ privacy and dignity during consultations."

Positive

"An area we identified as requiring improvement related to patient’s privacy and dignity."

Positive

"The practice did not have privacy screens in most consultation rooms and curtains or blinds were not present in one consulting room to respect patients’ privacy and dignity during consultations."

Positive

"How the regulation was not being met: The registered person did not make suitable arrangements to ensure the dignity and privacy of service users."

Positive

"The practice did not always respect patients’ privacy and dignity."

Neutral

"Most clinical rooms did not have privacy curtains or screens around the examination couch."

Positive

"National patient safety alerts were saved on the shared drive and disseminated by email to practice staff."

Positive

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

Positive

"Information about safety was recorded monitored appropriately reviewed and addressed."

Positive

"Monitoring safety and responding to risk The practice had systems processes and policies in place to manage and monitor risks to patients staff and visitors to the practice."

Positive

"The GPs told us clinical audits were often linked to medicines management information safety alerts or as a result of information from the quality and outcomes framework QOF."

Positive

"For example risks relating to fire safety business continuity and infection control had been carried out."

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

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

Positive

"For example reported incidents and national patient safety alerts as well as comments and complaints received from patients."

Positive

"We reviewed safety records incident reports and minutes of meetings where these were discussed for the last two years."

Positive

"Reliable safety systems and processes including safeguarding The practice had systems to manage and review risks to vulnerable children young people and adults."

Positive

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

Positive

"Health and safety audits were completed each year and we reviewed completed audits for the last two years."

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

"There was evidence that the practice had learnt from significant events to minimise the risks to patient safety and systems were in place to safeguard children from abuse."

Positive

"Health and safety audits including fire risk assessments were completed each year and we reviewed completed audits for the last two years."

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

"Following an incident relating to the abusive behaviour of a patient the practice had placed ‘zero tolerance’ posters and installed CCTV in the waiting room for the safety of patients and staff."

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

"The GPs and practice manager told us this was done so that each prescription script was checked for accuracy and safety before being issued to the patient."

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."

Neutral

"The GPs told us that safety alerts were cascaded to all GPs via email and individual GPs would action the alert."

Neutral

"The practice had put safety tape on the step and a notice on the wall to alert patients."

Neutral

"A GP partner informed us that the practice did not accept orders over the phone for safety reasons."

Positive

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

Positive

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

Positive

"The audit also referred to areas that required improvement such as replacing carpets in consulting rooms with impervious easy to clean flooring and replacing chairs with fabric covers in clinical areas with chairs which comply with infection control guidelines."

Positive

"For example risks relating to fire safety business continuity and infection control had been carried out."

Positive

"Risks to patients who used services were assessed and well managed such as those relating to infection control medicines management and business continuity."

Positive

"Cleanliness and infection control We observed the premises to be clean and tidy."

Positive

"An infection control policy and supporting procedures were available for staff to refer to which enabled them to plan and implement measures to control infection."

Positive

"For example there were lead nurses for infection control and safeguarding; a GP to lead on QOF; a designated member of staff to lead on health and safety; and the practice manager led on complaints."

Neutral

"There was a clear leadership structure and designated staff led in specific areas such as safeguarding infection control and complaints."

Neutral

"For example personal protective equipment including disposable gloves aprons and coverings were available for staff to use and staff were able to describe how they would use these to comply with the practice’s infection control policy."

Neutral

"The practice had two leads for infection control and they had undertaken further training to enable them to provide advice on the practice infection control policy and carry out staff training."

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."

Neutral

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

Neutral

"The two practice nurses had completed infection control training and provided inhouse training to other staff however the five GPs had not attended the training."

Positive

"The pack included information on the antenatal shared care programme between the practice and the hospital a healthy pregnancy book and information on diet and lifestyle advice during pregnancy."

Positive

"For example by offering advice on disease management diet smoking cessation and alcohol intake."

Neutral

"The practice offered a weekly baby clinic with the GPs and a health visitor and the nurses provided childhood immunisations."

Neutral

"The practice also offered a weekly baby clinic with the GPs and a health visitor and the nurses provided childhood immunisations."

Positive

"For example the practice had improved signage within the waiting room and had designated seating for patients with mobility needs."

Positive

"Tackling inequity and promoting equality The practice had recognised the needs of different groups in the planning of its services."

Neutral

"The practice had an equality and diversity policy in place and staff had received inhouse training."

Neutral

"Staff we spoke with confirmed that equality and diversity was regularly discussed at practice meetings."

Positive

"Complaints were discussed in staff meetings or sooner if required and staff we spoke with were able to outline what to do if a complaint was made to them."

Positive

"Some patients we spoke with were aware of the process to follow if they wished to make a complaint and others told us they would request the information from staff."

Positive

"None of the patients we spoke with had ever needed to make a complaint about the practice."

Positive

"The practice’s complaints and comments procedure provided guidance on how to make a complaint whom to speak to within the practice and external organisations where complaints could be raised."

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."

Positive

"Patients we spoke with had not made a complaint but said they would speak with staff if they needed to."

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."

Neutral

"The practice had a number of policies and procedures to govern activity and governance issues were discussed during the monthly practice meeting."

Neutral

"The practice regularly submitted governance and performance data to the clinical commissioning group CCG."

Neutral

"The practice held monthly staff meetings where governance issues were discussed."

Positive

"There were clear leadership and governance arrangements in place with staff describing a positive culture of openness and support within the practice."

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."