What is the Quality of Safety at Prentis Medical Centre

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 smoking and alcohol cessation."

Positive

"The areas where the provider must make improvements: • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care."

Positive

"Governance arrangements There were generally clear responsibilities roles and systems of accountability to support good governance and management."

Positive

"• Structures processes and systems to support good governance and management were clearly set out and understood."

Positive

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

Positive

"• There was one area where the practice’s governance systems had not ensured that assigned responsibilities were appropriate related to annual reviews for patients."

Positive

"We reviewed staff files on this inspection and found that all infection control fire safety information governance training had been completed in line with the timeframes set out in the action plan."

Positive

"Governance arrangements There were weaknesses in the practice’s governance systems which impacted on the practice’s ability to provide high quality safe care."

Positive

"However the effectiveness of this plan was hindered by insufficient staffing and deficiencies in governance and risk management."

Positive

"For example: • Though the practice had devised a structured plan for the upcoming year which detailed practice roles and responsibilities there were some areas where governance and oversight was lacking."

Positive

"– Requires improvement As part of our inspection process we also look at the quality of care for specific population groups."

Positive

"• Clinical audit had a positive impact on quality of care and outcomes for patients."

Positive

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

Positive

"This recognises the significant improvements made to the quality of care provided by this service."

Positive

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

Positive

"• We saw evidence of work undertaken to improve the quality of care for patients within the practice."

Positive

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

Positive

"The seven comment cards that contained mixed feedback also expressed satisfaction with the quality of care received but stated that they have to wait a long time to be seen by a GP when they attended for their appointment."

Positive

"Feedback provided from these services indicated that they felt the quality of care was high."

Positive

"The practice told us that they had taken action to improve the quality of care as a result of complaints."

Positive

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

Positive

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

Neutral

"The privacy curtains were not disposable."

Positive

"They also told us they were very happy 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

"This had after the first inspection focused on patient safety but was extending to other aspects of the practice’s care and services."

Positive

"The practice learned and shared lessons and took action to improve safety in the practice."

Positive

"• All staff received uptodate safeguarding and safety training appropriate to their role."

Positive

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

Positive

"• The safety and wellbeing of all staff was considered and promoted."

Positive

"• There were systems to assess monitor and manage risks to patient safety although there were aspects that needed to be strengthened particularly related to documentation of recruitment checks."

Positive

"• The practice conducted safety risk assessments."

Positive

"It had safety policies which were regularly reviewed and communicated to staff."

Positive

"Staff received safety information for the practice as part of their induction and refresher training."

Positive

"Risks to patients There were systems to assess monitor and manage risks to patient safety although there were aspects that needed to be strengthened."

Positive

"Track record on safety We had previously identified safety issues at the practice but on this inspection we found: • There were risk assessments in relation to safety issues and the practice took action to address areas of risk identified."

Positive

"• The practice monitored and reviewed activity this had led to safety improvements such as new monitoring systems."

Positive

"• There was a system for receiving and acting on safety alerts."

Positive

"However there were a number of areas including medicines management fire safety and arrangements for training and staff appraisals which had not yet been addressed."

Positive

"The practice had developed a number of new safety processes some in response to our feedback and others in response to risks that they had identified which were effective."

Neutral

"• The practice had clear systems to manage risk so that safety incidents were less likely to happen."

Positive

"Our key findings across all the areas we inspected were as follows: • There was an effective system in place for reporting and recording significant events and lessons were shared to make sure action was taken to improve safety in the practice."

Positive

"• There was an effective system in place for reporting and recording significant events and lessons were shared to make sure action was taken to improve safety in the practice."

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

"• The practice carried out a thorough analysis of these significant events and action was taken to improve safety and ensure that similar incidents did not occur in the future."

Positive

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

Positive

"However there were a number of areas including medicines management fire safety and arrangements for training and staff appraisals which had not been addressed."

Positive

"We reviewed staff files on this inspection and found that all infection control fire safety information governance training had been completed in line with the timeframes set out in the action plan."

Positive

"Overview of safety systems and processes The practice had systems processes and practices in place to keep patients safe and safeguarded from abuse however some of these were not effective: • Practice arrangements for safeguarding did not ensure that children and adults were protected 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

"• We saw evidence that although some risks to patient safety had been considered and mitigating action had been taken there were some health and safety risks which had not been considered or where action had not been taken to address the risks identified."

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."

Positive

"The practice had systems in place for acting on patient safety alerts and we saw evidence that appropriate action was taken in response to these alerts."

Positive

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

Positive

"How the regulation was not being met: Systems and processes did not operate effectively to ensure that risks to health safety and welfare of service users were mitigated."

Positive

"There was a health and safety policy available with a poster in the reception area."

Positive

"This covered such topics as safeguarding infection prevention and control health and safety and confidentiality."

Positive

"This included training in safeguarding fire safety awareness basic life support and information governance."

Positive

"Staff took steps to protect patients from abuse neglect harassment discrimination and breaches of their dignity and respect."

Positive

"• The practice had systems processes and practices in place to keep patients safe and safeguarded from abuse although most staff had yet to receive child and adult safeguarding training."

Positive

"• The practice had systems processes and practices in place to keep patients safe and safeguarded from abuse although most staff had still to receive child and adult safeguarding training."

Positive

"Overview of safety systems and processes The practice had systems processes and practices in place to keep patients safe and safeguarded from abuse however some of these were not effective: • Practice arrangements for safeguarding did not ensure that children and adults were protected from abuse."

Positive

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

Neutral

"• The systems processes and practices designed to keep patients safe and safeguarded from abuse were not sufficiently robust."

Positive

"The practice had failed to complete required recruitment checks and were not effectively managing risks including infection control legionella and fire safety."

Positive

"• Risk was poorly managed; for instance we found that adequate recruitment checks were not always completed prior to staff being appointed and infection control risks were not properly assessed or addressed."

Positive

"• There was still no clear leadership for infection control and recommendations from a fire risk assessment had still not been addressed."

Neutral

"There remained some issues with how medicines were managed with infection control training and appraisal."

Positive

"There were damaged chairs in the patient waiting area and a torn clinical couch which posed an infection control risk."

Positive

"• Risk was poorly managed for instance we found that adequate recruitment checks were not always completed prior to staff being appointed and infection control risks were not properly assessed or addressed."

Positive

"• The arrangements in place to monitor and act on risk were ineffective in respect of staff recruitment infection control management of medicines and emergencies."

Positive

"The practice was clean and tidy in all areas and we were provided minutes of a practice meeting after our inspection where the identity of the infection control lead was discussed."

Positive

"• Although staff roles were clear in most areas the lead for infection control was not aware that they held responsibility in this area and staff we spoke with were also not aware of who the lead was."

Positive

"• Ensure that the practice has an infection control lead that is adequately trained for the role and that all staff are aware of this person."

Positive

"However the healthcare assistant was not certain if they had been appointed to this role and some staff did not know the identity of the infection control lead."

Positive

"We reviewed staff files on this inspection and found that all infection control fire safety information governance training had been completed in line with the timeframes set out in the action plan."

Neutral

"All other infection control concerns had been addressed."

Neutral

"We identified infection control concerns in the staff toilets."

Neutral

"• Though we identified one area of infection control concern on the day of our inspection the practice had addressed all of the infection control risks identified at the previous inspection and appropriate standards of cleanliness and hygiene were maintained in all other areas of the practice."

Neutral

"All staff had now completed up to date infection control training."

Positive

"• Risks to patients associated with recruitment of staff management of medicines and emergencies and infection control were not always assessed and well managed which could have potentially placed patients at risk of harm."

Positive

"Our key findings across all the areas we inspected were as follows: • Risks to patients associated with recruitment of staff management of medicines and emergencies and infection control were not always assessed and well managed."

Positive

"• The arrangements in place to monitor and act on risk were ineffective in respect of staff recruitment infection control management of medicines and emergencies."

Positive

"However the lack of infection control training for staff had not been identified by the audit."

Positive

"The practice nurse was the infection control clinical lead but there was no evidence that they had received up to date training for this role."

Neutral

"A number of other staff also did not have up to date infection control training at the time of our inspection."

Neutral

"There was an infection control protocol in place."

Neutral

"Annual infection control audits were undertaken and we saw evidence that action was taken to address areas of concern."

Neutral

"For example we saw that though significant events were generally well managed there were occasions where investigations were not sufficiently thorough adequate recruitment checks were not always completed prior to staff being appointed and infection control risks were not properly assessed or addressed."

Positive

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

Positive

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

Positive

"Feedback provided previously from the services from these services commented on the excellent care provided by the surgery and the compassion for service users displayed by practice staff."

Positive

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

Positive

"• Staff recognised the importance of patients’ dignity and respect."

Positive

"Staff took steps to protect patients from abuse neglect harassment discrimination and breaches of their dignity and respect."

Positive

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

Positive

"The registered person had systems or processes in place that were operating ineffectively in that they failed to enable the registered person to ensure that accurate complete and contemporaneous records were being maintained securely in respect of each service user."

Positive

"• The arrangements in place to monitor and act on risk were ineffective in respect of staff recruitment infection control management of medicines and emergencies."

Neutral

"• The arrangements in place to monitor and act on risk were ineffective in respect of emergencies as the practice did not have a children’s oxygen mask the oxygen cylinder had expired and not all staff had received basic life support training."

Positive

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

Positive

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

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

"All feedback commented on the excellent service provided by the surgery and the care and compassion for service users displayed by practice staff."

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

"• The arrangements in place to monitor and act on risk were ineffective in respect of staff recruitment infection control management of medicines and emergencies."

Positive

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

Positive

"• The practice actively promoted equality and diversity."

Neutral

"Staff had received equality and diversity training and there were examples of reasonable adjustments made to address inequality."

Positive

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

Positive

"• Information about how to make a complaint or raise concerns was available and it was easy to do."

Neutral

"The PPG representative told us that the most frequent complaint from patients was on waiting times and that they looked forward to working with the practice to improve these."

Positive

"However we found some responses lacked sufficient detail on the circumstances which led to the complaint or the corrective action taken by the practice to address complaints."

Positive

"For example there was a leaflet available in reception and a complaint form that patients could fill in."

Positive

"Monitoring care and treatment The practice had a programme of quality improvement activity and routinely reviewed the effectiveness and appropriateness of the care provided."

Positive

"We saw evidence of team meetings where strategy was discussed and all staff were involved in discussion about how to improve services and the financial sustainability of the practice."