What is the Quality of Safety at The Thorndike Surgery

Neutral

"• Improvements to governance arrangements at the practice had taken place."

Positive

"• The practice had revised their system that helped ensure all governance documents were kept up to date."

Neutral

"Governance arrangements Improvements to governance arrangements at the practice had taken place."

Positive

"• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care."

Neutral

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

Positive

"Staff told us that the practice held regular staff meetings to help ensure they were uptodate with appropriate and relevant information for example outcomes of clinical meetings significant events and governance meetings."

Positive

"There were governance arrangements to continuously improve services."

Positive

"We were shown records that confirmed all staff had completed basic life support BLS information governance infection control confidentiality and safeguarding children and adult training."

Neutral

"Governance Arrangements The governance arrangements at the practice included the delegation of responsibilities to named GPs for example a lead for safeguarding."

Positive

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

Positive

"We based our judgement of the quality of care at this service on a combination of: • what we found when we inspected • information from our ongoing monitoring of data about services and • information from the provider patients the public and other organisations."

Positive

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

Positive

"This inspection was carried out to review in detail the actions taken by the practice to improve the quality of care and to confirm that the practice was now meeting legal requirements."

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

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

Positive

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

Positive

"At this inspection we found: • Leaders demonstrated that they understood the challenges to quality and sustainability and had identified the actions necessary to address these challenges."

Positive

"For example health and safety risks the potential risk of legionella in the building’s water system and risks associated with the lack of an effective system that managed test results and other incoming correspondence."

Positive

"• Improvements to risk management had been made with health and safety risks now being assessed and well managed."

Positive

"• Improvements to risk management had been made and health and safety risks were now being assessed and well managed."

Positive

"Overview of safety systems and processes • Staff told us that there was no local infection prevention team for the practice to liaise with in order to keep up to date with best practice."

Positive

"• Plans to address the safety issues associated with the shortage of clinical staff had been enhanced and implemented resulting in improvements."

Positive

"Monitoring risks to patients • The practice had revised the action plan that had been developed to address issues identified by their health and safety compliance audit."

Positive

"Plans to address the safety issues associated with the shortage of clinical staff had been enhanced and implemented resulting in improvements."

Positive

"• The practice had systems for notifiable safety incidents and ensured this information was shared with staff to help ensure appropriate action was taken."

Positive

"For example health and safety risks the potential risk of legionella in the building’s water system and risks associated with the lack of an effective system that managed test results and other incoming correspondence."

Positive

"• Lessons were shared to make sure action was taken to improve safety in the practice."

Positive

"We saw evidence that lessons were shared and action was taken to improve safety in the practice."

Positive

"For example the audit identified that lone workers had not been provided with sufficient information instruction and training to help ensure their safety at work."

Positive

"There was a fire evacuation plan and a fire safety policy which identified how staff could support patients with mobility problems to vacate the premises."

Positive

"• The practice had other risk assessments to monitor safety of the premises such as control of substances hazardous to health."

Positive

"• The practice had an up to date fire safety assessment and there were designated fire marshals."

Positive

"There was a health and safety policy available with a poster in the reception office which identified local health and safety representatives."

Positive

"We reviewed safety records incident reports and minutes of meetings where these were discussed."

Positive

"Overview of safety systems and processes There were systems processes and practices to help keep patients safe and safeguarded from abuse."

Positive

"Records showed that actions had been carried out to reduce some health and safety risks."

Positive

"• Records showed that all staff were up to date with fire safety training."

Positive

"• Staff received training that included: safeguarding fire safety awareness and information governance."

Positive

"The practice had systems that identified notifiable safety incidents."

Neutral

"However there were no other plans to effectively address the safety issues associated with the shortage of clinical staff that were current and that had been ongoing at the practice for some time."

Positive

"• The practice had a clear vision which had quality and safety as its top priority."

Positive

"The premises had an uptodate fire risk assessment and regular fire safety checks were recorded."

Positive

"The practice had completed risk assessments in relation to the premises such as fire risk assessments health and safety and security of the building external and internal."

Positive

"We looked at audits related to safety alerts and saw that these provided a clear audit trail of actions taken by the GPs to ensure patients safety."

Positive

"Reliable safety systems and processes including safeguarding The practice had effective systems and processes for safeguarding vulnerable adults and children who used services."

Positive

"National data collected from incidentsevents and alerts was monitored assessed and used to improve patient safety within the practice."

Positive

"Management meetings were held on a regular basis to consider quality safety and performance within the practice."

Positive

"Learning and improvement from safety incidents The practice had a system for reporting recording and monitoring significant events incidents and accidents."

Positive

"There were service and maintenance contracts with specialist contractors who undertook regular safety checks and maintained specialist equipment."

Positive

"There were arrangements for monitoring safety using information from audits risk assessments and routine checks that were undertaken by staff."

Positive

"Records showed there were service and maintenance contracts with specialist contractors who undertook regular safety checks and maintained specialist equipment."

Positive

"Training had been provided to staff in respect of fire safety awareness."

Positive

"Any information received in relation to safety alerts was cascaded either electronically or during practice meetings to the staff team."

Positive

"The practice had a health and safety policy."

Neutral

"For example infection control training was being added to the induction training given to all clinical staff when they commenced employment with the practice."

Neutral

"There was an infection control protocol and staff had received up to date infection prevention and control training."

Positive

"The practice had an infection control policy which included a range of procedures and protocols for staff to follow for example hand hygiene a spillage protocol management of sharps injuries and clinical and hazardous waste management."

Positive

"We were shown records that confirmed all staff had completed basic life support BLS information governance infection control confidentiality and safeguarding children and adult training."

Neutral

"The policy identified a member of staff as the infection control lead for the practice and we spoke with them."

Neutral

"Staff told us they had received training in infection control and we saw evidence of training updates in infection control for all members of the clinical staff team."

Positive

"Kindness dignity respect and compassion We spoke with five patients during the inspection."

Positive

"• Patients said they were treated with compassion dignity and respect."

Positive

"They said their dignity was maintained they were treated with respect and the practice was always clean and tidy."

Positive

"• Patients said 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 comment cards we received were positive about the emotional support provided by the practice."

Positive

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

Positive

"They considered their dignity and privacy had been respected and that staff were polite friendly and caring."

Positive

"Patients’ privacy and dignity was respected and protected and their confidential information was managed appropriately."

Positive

"• Patients said they were treated with dignity and respect and they were involved in their care and decisions about their treatment."

Positive

"There were systems to help ensure that patients’ privacy and dignity was protected at all times."

Positive

"All patients we spoke with considered their dignity and privacy had been respected."

Positive

"Patients with children told us in their comment cards that the practice staff treated their children with the same respect as they would when speaking with adults."

Positive

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

Positive

"Training had been provided to staff in respect of fire safety awareness."

Positive

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

Positive

"They considered their dignity and privacy had been respected and that staff were polite friendly and caring."

Positive

"Patients’ privacy and dignity was respected and protected and their confidential information was managed appropriately."

Positive

"There were systems to help ensure that patients’ privacy and dignity was protected at all times."

Positive

"All patients we spoke with considered their dignity and privacy had been respected."

Positive

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

Neutral

"Disposable privacy curtains were used in clinical rooms and there was a schedule for routinely changing them."

Neutral

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

Positive

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

Positive

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

Positive

"Other health care professionals who had contact with vulnerable children and adults were involved in safeguarding the patients from the risk of harm and abuse as multidisciplinary safeguarding information held at the practice was appropriately being shared with the health visitor for the area."

Positive

"This gave patients the option of taking their complaint further if they were not happy with the way in which the practice responded."

Positive

"Two patients told us that they had had cause to complain in the past and that their complaint was taken seriously that they were informed of all stages of any subsequent investigation and the conclusionoutcome of their findings."

Positive

"Other health care professionals who had contact with vulnerable children and adults were involved in safeguarding the patients from the risk of harm and abuse as multidisciplinary safeguarding information held at the practice was appropriately being shared with the health visitor for the area."

Positive

"Staff told us that where family difficulties were identified referrals were made into the health visitor who provided specialist support for mothers babies children and young people."

Positive

"For example disciplinary procedures induction policy as well as equality and harassment and bullying at work."

Neutral

"Tackling inequity and promoting equality The premises were accessible for patients with disabilities."