What is the Quality of Safety at Mitcheldean Surgery

Positive

"Track record on safety The practice had a good safety record."

Positive

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

Positive

"• All staff received uptodate safeguarding and safety training appropriate to their role. . They knew how to identify and report concerns."

Positive

"• There was a strong emphasis on the safety and wellbeing of all staff."

Positive

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

Positive

"At this inspection we found: • The practice had systems to manage risk so that safety incidents were less likely to happen."

Positive

"• The practice conducted safety risk assessments in a number of areas ."

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

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

Neutral

"• The practice had taken the decision to employ the services of a Health and Safety company to undertake an annual assessment of risk in relation to safety issues."

Neutral

"This helped it to understand risks and gave a clear accurate and current picture that led to safety improvements."

Positive

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

Positive

"All staff were fully trained on the system and commented positively about the system’s safety and ease of use."

Positive

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

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

"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 representative."

Positive

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

Positive

"National patient safety alerts such as from the Medicines and Healthcare Products Regulatory Agency MHRA were disseminated through the practice manager to relevant practice staff."

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

"This covered fire safety legionella checks first aid portable electrical equipment and check of the building."

Positive

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

Positive

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

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

"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."

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

"The evidence from these sources showed patients were satisfied with how they were treated and that they had been treated 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."

Positive

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

Positive

"The survey covered areas such as satisfaction with opening hours appointment times ability for GPs to listen to patients and respect shown."

Positive

"Curtains were provided in consulting rooms and treatment rooms so 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 if patients’ privacy and dignity was not being respected they would raise these with the practice manager."

Positive

"The areas where the provider should make improvements are: • Review systems and processes across all aspects of care so that governance is consistently effective."

Positive

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

Positive

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

Positive

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

Neutral

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

Positive

"Good 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 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

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

Positive

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

Positive

"Curtains were provided in consulting rooms and treatment rooms so 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 if patients’ privacy and dignity was not being respected they would raise these with the practice manager."

Neutral

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

Positive

"We were told that liaison with the local infection prevention teams in order to keep up to date with best practice did not take place and the infection control lead was unsure of where further advice could be obtained from if needed."

Neutral

"• There were processes for providing all staff with the development they need with the exception of infection control training for the infection control lead."

Positive

"Cleanliness and infection control We found at the last inspection no evidence of an infection control audit."

Positive

"They informed us that they intended to complete this audit every quarter to ensure the practice was meeting infection control guidelines."

Neutral

"This included the completion of regular infection control audits."

Neutral

"Risks to patients were assessed and well managed including improvements made since our last inspection to improve infection control and medicines management."

Neutral

"We reviewed infection control procedures at this inspection."

Neutral

"We saw a new infection control lead person had been appointed."

Positive

"• Ensure infection control audits were completed at appropriate timescales to ensure the practice followed adequate infection control procedures to keep patients safe from the risk of infection."

Positive

"Also there was no evidence that the practice infection control procedures had been audited in the last year."

Positive

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

Positive

"There had been a recent change in the lead for infection control and staff were unable to find the latest infection control audit."

Neutral

"All staff received training about infection control specific to their role."

Neutral

"For example there was a lead nurse for infection control and a GP partner was the lead for safeguarding."

Positive

"• The practice actively promoted equality and diversity."

Neutral

"Staff had received equality and diversity training."

Positive

"Tackling inequity and promoting equality There was a proactive approach to understanding the needs of different groups of patients and to deliver care in a way that meets these needs and promotes equality."

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."

Positive

"• Quality and sustainability were discussed in relevant meetings where all staff had sufficient access to information."

Positive

"For example following the success of the quality assurance of complaints by a PPG member the practice had decided to introduce the same process for quality assurance of the handling of significant events."

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

"• The practice was actively involved in quality improvement activity."