What is the Quality of Safety at Belvoir Health Group

Positive

"Although the complaints leaflet available to patients at the practice did not state that they could direct their complaint to NHS England rather than the practice in addition to contacting the Parliamentary Health Service Ombudsman to investigate second stage complaints."

Positive

"These were acknowledged investigated and responded to in line with the practice’s policy except for one complaint that was ongoing."

Positive

"Not all patients were aware of the process to follow should they wish to make a complaint but they said that they had not had cause to do so."

Positive

"We saw that the practice had completed various audits to monitor and improve the quality of care and services for patients."

Positive

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

Positive

"We observed that patients’ privacy dignity and confidentially were maintained; staff were respectful and polite when dealing with patients."

Positive

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

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 business manager."

Neutral

"Patients privacy and confidentially was also maintained."

Positive

"Areas for improvement Action the service SHOULD take to improve • Further develop the clinical audit programme linked to medicines management information safety alerts and significant events to improve outcomes for patients."

Positive

"• Systems were in place to assess and review information about the quality and safety of services that people received although the clinical audit programme required developing to further improve outcomes for patients."

Positive

"Governance arrangements We found that effective systems were in place for gathering and reviewing information about the quality and safety of services that people received."

Positive

"Importantly the provider should: • Further develop the clinical audit programme linked to medicines management information safety alerts and significant events to improve outcomes for patients."

Positive

"The GP partners acknowledged the need to develop the clinical audit programme across the three branches linked to medicines management information safety alerts and significant events to improve outcomes for patients."

Positive

"Systems were in place to assess and review information about the quality and safety of services that people received."

Positive

"A system was in place to ensure that staff were aware of national patient safety alerts and relevant safety issues and where action needed to be taken."

Positive

"Records showed that safety incidents and concerns were appropriately dealt with."

Positive

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

Positive

"We saw that the practice had completed various health and safety risk assessments including actions required to reduce and manage the risks."

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

"This acted as a safety net for patients who did not or could not leave their houses."

Positive

"They acknowledged the need to develop the audit programme linked to medicines management information safety alerts and significant events given the large size of the practice and clinical team covering the three branches."

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 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 had a health and safety policy which staff had access to."

Positive

"There was also a health and safety representative."

Positive

"A quarterly health and safety meetings were held covering all three branches."

Positive

"The minutes of meetings showed that a wide range of health and safety issues were discussed and acted on at the meetings."

Positive

"Records showed that health and safety checks had been carried out at the required intervals."

Neutral

"This included mandatory courses such as infection control fire safety and basic life support."

Positive

"Records showed that monthly meetings were held with relevant professionals to share information and discuss children and adults who were considered to be at risk of harm or abuse across the three branches."

Positive

"Staff knew how to recognise signs of abuse in older people vulnerable adults and children and who to speak to in the practice if they had a safeguarding concern."

Positive

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

Positive

"We were shown a new infection control audit which was comprehensive."

Positive

"The infection control lead agreed to ensure that the remedial actions that had yet to be completed included timescales for completion."

Positive

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

Neutral

"The practice had a lead for infection control who had undertaken relevant training to enable them to advise staff on the policy."

Neutral

"All staff received induction training about infection control specific to their role and an annual update."

Neutral

"They also had access to the policy and procedures to enable them to apply infection control measures."

Neutral

"Staff told us of various improvements that had been made to the premises to meet infection control standards."

Neutral

"These roles included infection control medicines management as well as QOF QOF is a voluntary incentive scheme for GP practices in the UK."

Neutral

"This included mandatory courses such as infection control fire safety and basic life support."

Neutral

"The children’s meetings were attended by GPs the health visitor midwife and school nurses."

Neutral

"They were looking to set up a virtual PPG group by use of emails and by setting up a facebook page for patients to sign up to represent further patient groups."

Positive

"They described the staff as friendly helpful and caring and felt that they were treated with dignity and respect."

Positive

"They said that they were treated with kindness dignity and respect and were involved in decisions about their care and treatment."

Positive

"Common themes were that patients were treated with dignity and respect and that the staff were caring and helpful."

Positive

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

Positive

"Patients described the staff as friendly and caring and said they were treated with dignity and respect."

Positive

"We observed that patients were treated with dignity respect and kindness during interactions with staff."

Positive

"The data showed patients were treated with care dignity and respect."

Positive

"We observed that patients’ privacy dignity and confidentially were maintained; staff were respectful and polite when dealing with patients."

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 business manager."

Positive

"We were shown the electronic staff handbook which included sections on equality harassment and bullying at work."

Positive

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

Neutral

"Staff we spoke with said that they had attended equality and diversity training."

Neutral

"They also said that equality and diversity issues were discussed at team meetings."

Positive

"However three monthly clinical governance meetings had recently been introduced out of the need to improve the sharing of clinical knowledge and learning."

Positive

"Three monthly clinical governance meetings had recently been introduced out of the need to improve the sharing of clinical knowledge and learning."

Neutral

"However three monthly clinical governance meetings had recently been introduced which involved the GPs and nurse manager."