What is the Quality of Safety at St Ann's Medical Centre

Positive

"• Improved arrangements for the storage of oxygen and ensured appropriate and consistent signage was implemented for oxygen storage areas."

Positive

"• Provided suitable storage for oxygen and ensured appropriate and consistent signage was implemented for oxygen storage areas."

Positive

"The practice also provided evidence of some areas highlighted for improvement at the last inspection For example health and safety signage relating to storage of oxygen had been reviewed and oxygen storage areas were now identified by consistent signage."

Positive

"• Improve arrangements for storage of oxygen at Kimberworth surgery and ensure appropriate and consistent signage is implemented for all oxygen storage areas across the three sites."

Positive

"Arrangements for safe storage of oxygen at Kimberworth Surgery required review and appropriate and consistent signage was not in place for all oxygen storage areas across the three sites."

Positive

"Health and safety signage relating to storage of oxygen was inconsistent and not all oxygen storage areas were identified by signs in both the main site and the branches."

Positive

"We issued a requirement notice in respect of these issues."

Positive

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

Positive

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

Positive

"Results from the national GP patient survey showed patients were satisfied with how they were treated and that this was with compassion dignity and respect."

Positive

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

Positive

"They told us they were treated with respect and said their privacy and dignity was protected."

Positive

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

Positive

"The deputy manager told us they had recognised that responses had not always been made in a timely manner and they had reviewed their policy and procedure in respect of this."

Positive

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

Positive

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

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

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

Positive

"We found there had been some improvement in governance arrangements although these had not always been effectively implemented and the practice continued to require improvement in well led."

Positive

"Our key findings were as follows: • There had been improvement in governance arrangements to ensure vaccines were stored safely."

Positive

"Our key findings were as follows: • There had been some improvement in governance arrangements and staff responsibilities had been clarified to ensure governance systems were implemented."

Positive

"Importantly the provider must: • Improve governance arrangements and clarify staff responsibilities to ensure governance systems are fully implemented."

Positive

"• The practice does however need to improve governance arrangements and clarify staff responsibilities to ensure systems are fully implemented."

Positive

"• The provider must improve governance arrangements and clarify staff responsibilities to ensure systems are fully implemented."

Positive

"This was because: • There was a lack of monitoring and oversight to ensure governance systems were fully implemented."

Positive

"However good standards of clinical care and treatment had been maintained and patients were satisfied with the care they received The practice had a number of policies and procedures to govern activity and held regular governance meetings."

Positive

"Governance arrangements The practice had an overarching governance framework which supported the delivery of the strategy and good quality care."

Neutral

"For example the recruitment procedure and infection control action plan had been implemented and monitored."

Positive

"Cleanliness and infection control We saw there were improved processes in place for the management of infection prevention and control IPC."

Neutral

"For example the recruitment procedure infection control action plan and procedures to monitor vaccine fridge temperatures at the branch surgery must be fully implemented and monitored."

Neutral

"For example the recruitment procedure infection control action plan and procedures to monitor vaccine fridge temperatures at the branch surgery must be implemented and monitored."

Positive

"• Risks to patients were not always assessed and well managed and we found shortfalls relating to recruitment checks infection control and oxygen storage."

Positive

"For example monitoring systems were not in place to ensure that policies and procedures for recruitment health and safety and infection control were implemented and standards maintained."

Positive

"Cleanliness and infection control • We observed all three premises to be clean and tidy."

Neutral

"Disposable privacy curtains were provided at the main site and also at the branch site and a record of when these were last changed were now recorded on each curtain."

Positive

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

Positive

"They told us they were treated with respect and said their privacy and dignity was protected."

Positive

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

Neutral

"Disposable privacy curtains were provided at the main site but fabric curtains were in place at the branch sites."

Positive

"Good ––– People with long term conditions The provider is rated as requires improvement for safety responsive and for wellled and good for effective and caring."

Positive

"Good ––– Families children and young people The provider is rated as good for safety and responsive and requires improvement for wellled."

Positive

"Good ––– Working age people including those recently retired and students The provider is rated as good for safety and responsive and requires improvement for wellled."

Positive

"Good ––– People whose circumstances may make them vulnerable The provider is rated as good for safety and responsive and requires improvement for wellled."

Positive

"Good ––– People experiencing poor mental health including people with dementia The provider is rated as good for safety and responsive and requires improvement for wellled."

Positive

"Older people The provider is rated as good for safety and responsive and requires improvement for wellled."

Positive

"The provider had also improved records relating to the management of patient safety alerts and we observed records now evidenced the actions taken in response to alerts."

Positive

"The practice also provided evidence of some areas highlighted for improvement at the last inspection For example health and safety signage relating to storage of oxygen had been reviewed and oxygen storage areas were now identified by consistent signage."

Positive

"Overview of safety systems and processes Disclosure and barring checks DBS had been completed for staff undertaking chaperone duties and the practice had either obtained or was in the process of obtaining DBS checks for all staff employed."

Positive

"Requires improvement ––– People with long term conditions The provider is rated as requires improvement for safety responsive and for wellled and good for effective and caring."

Positive

"Requires improvement ––– Families children and young people The provider is rated as requires improvement for safety responsive and for wellled and good for effective and caring."

Positive

"Requires improvement ––– Working age people including those recently retired and students The provider is rated as requires improvement for safety responsive and for wellled and good for effective and caring."

Positive

"Older people The provider is rated as requires improvement for safety responsive and for wellled and good for effective and caring."

Positive

"Requires improvement ––– People experiencing poor mental health including people with dementia The provider is rated as requires improvement for safety responsive and for wellled and good for effective and caring."

Positive

"People whose circumstances may make them vulnerable The provider is rated as requires improvement for safety responsive and for wellled and good for effective and caring."

Positive

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

Positive

"• There were procedures in place for monitoring and managing risks to patient and staff safety and a site manager was responsible for health and safety matters at the main site and Kimberworth branch surgery."

Positive

"Most information about safety matters was recorded monitored reviewed and addressed."

Positive

"For example monitoring systems were not in place to ensure that policies and procedures for recruitment health and safety and infection control were implemented and standards maintained."

Positive

"Overview of safety systems and processes The practice had systems processes and practices in place to keep people safe although there were shortfalls in some areas."

Positive

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

Positive

"However discussions with members of staff from the nursing team and the management team showed there was some confusion about who received and was dealing with safety alerts coming into the practice."

Positive

"They said they had previously kept an electronic log of safety alerts and action taken but this could not be found on the day of the inspection."

Positive

"Health and safety signage relating to storage of oxygen was inconsistent and not all oxygen storage areas were identified by signs in both the main site and the branches."

Neutral

"• The practice had an induction programme for newly appointed nonclinical members of staff that covered such topics as safeguarding fire safety health and safety and confidentiality."

Positive

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

Positive

"• Arrangements were in place to safeguard adults and children from abuse that reflected relevant legislation and local requirements and policies were accessible to all staff."

Positive

"Clinical audits were carried out to demonstrate quality improvement and all relevant staff were involved to improve care and treatment and people’s outcomes."