What is the Quality of Safety at The Portland Road Practice

Positive

"Data from the national GP patient survey showed the practice was rated broadly in line with the CCG average for dignity and respect and involvement in decisions and support in their care and treatment."

Positive

"Patients indicated that staff were caring and treated them with dignity and respect and involved them in decisions about their care and treatment."

Positive

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

Positive

"Patientcarer support to cope emotionally with care and treatment The patient survey information we reviewed showed patients were positive about the emotional support provided by the practice and rated it well in this area."

Positive

"The majority told us they were satisfied with the care provided by the practice and said their dignity and privacy was respected."

Positive

"Several said the practice offered an excellent service and the staff treated them with dignity and respect."

Positive

"Patients indicated that staff were caring and treated them with dignity and respect."

Positive

"We observed during the inspection that staff treated patients with kindness and respect."

Positive

"The survey also showed patients were positive about the helpfulness of receptionists and the emotional support provided by the practice and rated it well in these areas."

Positive

"Disposable curtains were provided in most of the consulting rooms and treatment rooms so that patients’ privacy and dignity was maintained during examinations investigations and treatments."

Positive

"Patients were mostly positive about the compassion dignity and respect they were shown."

Positive

"Patients told us staff were caring and treated them with dignity and respect."

Positive

"They indicated that staff were caring and treated them with dignity and respect."

Positive

"Patients who used the practice told us that they were involved in decisions about their care and treatment and they were treated with dignity and respect."

Positive

"However there was scope for improvement in ensuring patients’ privacy and dignity during telephone calls and their attendance at the practice."

Positive

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

Positive

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

Positive

"The majority told us they were satisfied with the care provided by the practice and said their dignity and privacy was respected."

Positive

"Disposable curtains were provided in most of the consulting rooms and treatment rooms so that patients’ privacy and dignity was maintained during examinations investigations and treatments."

Neutral

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

Positive

"However there was scope for improvement in ensuring patients’ privacy and dignity during telephone calls and their attendance at the practice."

Positive

"Lack of signage on consulting room doors to show they were occupied meant that there was a potential for privacy to be compromised."

Positive

"They also expressed dissatisfaction with the way they had been dealt with by staff and the lack of privacy and confidentiality of the reception area."

Positive

"There were appropriate systems for managing and disseminating patient safety alerts and guidance issued by the National Institute for Health and Care Excellence NICE."

Positive

"Our key findings were as follows: • The practice had in most respects addressed concerns identified at our previous inspection and now complied with the essential standards of quality and safety that were not being met."

Positive

"Reliable safety systems and processes including safeguarding The practice had appropriate safeguarding policies in place for both children and vulnerable adults including contact details for local safeguarding agencies."

Positive

"In addition the systems in place to identify assess and manage other risks to the health safety and welfare of people who use the service and others were not effective."

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

"The practice also had a health and safety policy and health and safety information was displayed for staff to see."

Positive

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

Positive

"Staff received appropriate fire safety instruction during induction and the majority of staff had received update training within the last year."

Neutral

"Appropriate fire alarm testing and evacuation drills were now in place and steps had been taken to improve the safety and security of the premises."

Positive

"The practice had a number of policies and procedures in place to ensure safe patient care such as health and safety infection control and dealing with significant events."

Positive

"Our findings Safe Patient Care The patients we spoke with trusted the GPs and nurses and raised no concerns about their safety at the practice."

Positive

"Staff received training in fire safety and the practice had a named fire marshal although there was no named deputy to cover for absences."

Positive

"In addition the systems in place to identify assess and manage other risks to the health safety and welfare of people who use the service and others were not effective."

Positive

"The provider reviewed incidents to improve the safety of the service."

Positive

"The majority of staff were due for refresher training in child protection and all doctors in conflict resolution; infection control fire safety and safeguarding vulnerable adults."

Positive

"However shortcomings in relation to the safety and security of the practice premises infection control staff recruitment practices and security of records did not protect patients in this and other population groups sufficiently against the risks associated with these areas."

Positive

"• There were a number of potential risks relating to safety of the premises."

Positive

"The regulations were not being met in relation to safety and suitability of premises."

Positive

"We found a number of potential risks relating to the safety of the premises in areas patients had access to."

Positive

"We found a number of potential risks relating to safety of the premises."

Positive

"The provider had a number of arrangements in place for monitoring safety and responding to risk related to the operation of the premises."

Positive

"The practice’s health and safety risk assessment had also not been communicated to staff."

Positive

"These gaps in records had not been identified and assessed as potential risks to the health welfare and safety of people using the service staff and other visitors to the practice."

Neutral

"It was not clear how recommended controls identified from the practice’s health and safety risk assessment were communicated within the practice and followed up and implemented."

Neutral

"The patients we spoke with in this population group raised no concerns about their safety in using the service."

Positive

"The practice had a zero tolerance policy for abuse regarding any patient who is physically or verbally abusive or threatening towards staff or other patients."

Positive

"Staff knew how to recognise signs of abuse and the process to follow in the event of any safeguarding concerns."

Positive

"The practice had nominated GP lead for safeguarding and staff we spoke with knew who the lead was how to recognise signs of abuse and the processes to follow."

Positive

"There were procedures in place to identify abuse and reduce the risk of abuse happening."

Positive

"Staff we spoke with understood how to recognise signs of abuse and the process to follow if they had concerns."

Positive

"The practice used the NHS elearning skills academy for health website for mandatory training including equality and diversity conflict resolution infection control child protection safeguarding of vulnerable adults and fire safety."

Positive

"Separate clinical practice policies and procedures including policies on consent infection control and chaperoning were also accessible to all staff."

Positive

"There were appropriate infection control policies and procedures in place."

Positive

"Cleanliness and infection control risk assessments had been completed and we saw from the minutes of practice meetings cleaning standards and infection control were regularly reviewed."

Positive

"Cleaning standards and infection control inspections were now conducted weekly and actions audited to ensure compliance."

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 named leads for safeguarding infection control complaints and HR matters."

Neutral

"For example personal protective equipment including spill kits 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 nurse was the lead for infection control who had undertaken further training to enable them to provide advice on the practice infection control policy and carry out staff training."

Neutral

"All staff received induction training about infection control specific to their role and received periodic updates."

Neutral

"We saw evidence that the practice carried out weekly infection control inspections and commissioned external audits annually and that any improvements identified for action were completed on time."

Neutral

"Minutes of practice meetings showed that cleaning and infection control were discussed regularly."

Positive

"The practice had a number of policies and procedures in place to ensure safe patient care such as health and safety infection control and dealing with significant events."

Positive

"The practice used the NHS elearning skills academy for health website for mandatory training including equality and diversity conflict resolution infection control child protection safeguarding of vulnerable adults and fire safety."

Positive

"The majority of staff were due for refresher training in child protection and all doctors in conflict resolution; infection control fire safety and safeguarding vulnerable adults."

Positive

"However shortcomings in relation to the layout and maintenance of the practice premises infection control staff recruitment practices and security of records did not protect patients in this and other population groups sufficiently against the risks associated with these areas."

Positive

"Improvements were needed in a number of areas to ensure patients were fully protected against risk: • Patients were not sufficiently protected from the risk of infection because infection control arrangements in place and standards of cleanliness id not fully protect patients from the risk of infection."

Positive

"However shortcomings in relation to the safety and security of the practice premises infection control staff recruitment practices and security of records did not protect patients in this and other population groups sufficiently against the risks associated with these areas."

Positive

"There were inadequate arrangements in place to ensure the service was safe: • The infection control arrangements in place did not fully protect patients from the risk of infection."

Positive

"Cleanliness & Infection Control The practice had a cleaning contract an infection control policy named staff responsible for infection control the provision of personal protective equipment and a waste management contract."

Positive

"However we found the infection control arrangements in place did not fully protect patients from the risk of infection."

Neutral

"Improvements were required in the operation of infection control systems and in the standards of cleanliness and hygiene in relation to premises and equipment."

Neutral

"The majority of staff had been trained in infection control and had completed recent refresher training; doctors were due to complete this training shortly."

Positive

"To meet the needs of this population the practice ran dedicated nurse and baby clinics and a health visitor led dropin clinic on Thursday afternoons."

Neutral

"The practice provided a weekly baby clinic on a dropin basis run by a health visitor on Thursday afternoons."

Neutral

"The practice provided a weekly baby clinic on a dropin basis run by a health visitor on Thursday afternoons."

Neutral

"If these were not ready on arrival the GPs were asked to sign the prescription and the practice offered to fax a copy to the patient’s pharmacy to speed up collection."

Positive

"The door opened outwards onto the stairway and there was no signage warning of this which could put anybody passing on the stairs at risk."

Positive

"Lack of signage on consulting room doors to show they were occupied meant that there was a potential for privacy to be compromised."

Positive

"One of the consulting rooms on the first floor had a back door which was unlocked and had no signage that the room was in use."

Neutral

"If these were not ready on arrival the GPs were asked to sign the prescription and the practice offered to fax a copy to the patient’s pharmacy to speed up collection."

Positive

"The practice used the NHS elearning skills academy for health website for mandatory training including equality and diversity conflict resolution infection control child protection safeguarding of vulnerable adults and fire safety."

Positive

"We reviewed a number of policies for example recruitment induction and equality and diversity which were in place to support staff."

Positive

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

Neutral

"Staff were made aware of the policy as part of the induction process and staff we spoke with understood patients’ equality and diversity needs covering a diverse population of patients."

Neutral

"The GP partners practice manager and four of the receptionadministration team had completed equality and diversity training."

Neutral

"We saw that policies had been reviewed and noted from meeting minutes that they had been drawn to the attention of staff with instructions to familiarise themselves with the policies including whistleblowing safeguarding and equality and diversity."

Positive

"The practice used the NHS elearning skills academy for health website for mandatory training including equality and diversity conflict resolution infection control child protection safeguarding of vulnerable adults and fire safety."

Positive

"However the practice leaflet stated a commitment to equality in the provision of services to all who came into contact with the practice."

Positive

"The complaints procedure explained how patients could pursue matters further with other organisations if they were dissatisfied with the handling of their complaint including the Parliamentary and Health Service Ombudsman PHSO."

Positive

"We were provided with an analysis of complaints received in the last year which included a summary of the complaint action taken the outcome and lessons learned."

Positive

"Patients we spoke with had not needed to make a complaint about the practice."

Positive

"For example in relation to a complaint about sharing patient information with other agencies where staff were reminded when communicating with other services to ensure that only appropriate patient information was included."

Positive

"Patients we spoke with told us they had not had any reason to make a formal complaint about the service."

Positive

"There were governance arrangements in place through which risk and performance monitoring took place and service improvements were identified."

Neutral

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

Neutral

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

Neutral

"The leadership management and governance arrangements did not ensure the service was sufficiently well led."

Neutral

"The governance arrangements included systems to monitor the quality of service manage risks and learn from incidents."

Neutral

"The leadership management and governance arrangements did not ensure the service was sufficiently well led for patients in this and other population groups."

Neutral

"There were individual job descriptions for each post and named leads for specific areas including clinical governance safeguarding prescribing and infection control."

Neutral

"However the leadership management and governance arrangements did not ensure the service was sufficiently well led for patients in this and other population groups."

Positive

"The regulations were not being met in relation to assessing and monitoring the quality of service provision."

Neutral

"The governance arrangements included systems to monitor the quality of service manage risks and learn from incidents."