What is the Quality of Facilities at St Martins Medical Centre

Positive

"• A practice nurse and health care assistant were the infection prevention and control IPC clinical leads who liaised with the local infection prevention teams to keep up to date with best practice."

Positive

"• Where a patient’s mental capacity to consent to care or treatment was unclear the GP or practice nurse assessed the patient’s capacity and recorded the outcome of the assessment."

Positive

"The GPs and practice nurse were trained to child protection or child safeguarding level three the health care assistant to level two and nonclinical staff level one."

Neutral

"During our visit we: • Spoke with a range of staff including the GP partners a salaried GP practice nurse practice manager and two receptionists administrators."

Positive

"• Where a patient’s mental capacity to consent to care or treatment was unclear the GP or practice nurse assessed the patient’s capacity and recorded the outcome of the assessment."

Positive

"Patient Group Directions PGDs had been adopted by the practice to allow the nurse to administer medicines in line with legislation."

Positive

"They were checked weekly by the practice nurse and all the medicines we checked were in date and fit for use."

Positive

"For example ineffective monitoring of procedures for: infection prevention and control; emergency medicines; monitoring patients on warfarin; uncollected repeat prescriptions; and monitoring fridge temperatures."

Positive

"Management monitoring and improving outcomes for people The practice used the information collected for the Quality and Outcomes Framework QOF and performance against national screening programmes to monitor outcomes for patients."

Positive

"However there were systemic weaknesses in governance systems relating to infection prevention and control emergency medicines monitoring patients on warfarin uncollected repeat prescriptions and monitoring fridge temperatures."

Positive

"The practice needed to improve the processes for monitoring patients taking warfarin; uncollected repeat prescriptions; responding to emergencies; infection prevention and control; and monitoring fridge temperatures."

Positive

"The practice needed to improve the processes for: monitoring patients taking warfarin; uncollected repeat prescriptions; responding to emergencies; infection prevention and control; and monitoring fridge temperatures."

Positive

"This was not in line with current national guidelines which recommend blood test monitoring at least every three months."

Positive

"There were procedures for assessing monitoring and managing risks to patient and staff safety."

Neutral

"It is based on a combination of what we found when we inspected information from our ongoing monitoring of data about services and information given to us from the provider patients the public and other organisations."

Neutral

"We made the practice aware of this and were told they would review their protocols for monitoring patients taking warfarin."

Neutral

"They planned to involve the practice pharmacist in warfarin monitoring going forward."

Neutral

"• There were arrangements for planning and monitoring the number of staff and mix of staff needed to meet patients’ needs."

Neutral

"In particular: • Records for monitoring fridge temperatures were not consistently kept."

Neutral

"• The processes for monitoring patients taking warfarin were inconsistent."

Positive

"• Ensure policies and protocols are in place and up to date to assist staff with significant event reporting infection control the secure storage and monitoring of prescriptions repeat prescribing health and safety and referrals."

Positive

"Management monitoring and improving outcomes for people The practice used the information collected for the Quality and Outcomes Framework QOF and performance against national screening programmes to monitor outcomes for patients."

Positive

"Policies or protocols were not in place or were not updated for significant event reporting infection control the secure storage and monitoring of prescriptions repeat prescribing health and safety or referrals."

Neutral

"It is based on a combination of what we found when we inspected information from our ongoing monitoring of data about services and information given to us from the provider patients the public and other organisations."

Neutral

"• Arrangements were in place for planning and monitoring the number of staff and mix of staff needed to meet patients’ needs."

Neutral

"The practice could refer patients they assessed as requiring assistance and monitoring over the weekend."

Positive

"• The practice identified at an early stage older patients who may need palliative care as they were approaching the end of life."

Positive

"The practice acknowledged that this was an error as the receptionist was unclear of the flu vaccine guidelines and eligibility and the patient was given an apology."

Positive

"The practice service is registered with the Care Quality Commission CQC to provide the regulated activities of diagnostic and screening procedures; treatment of disease disorder and injury; family planning services; surgical procedures; and maternity and midwifery services."

Positive

"The service is registered with the Care Quality Commission to provide the regulated activities of diagnostic and screening procedures; treatment of disease disorder and injury; maternity and midwifery services; family planning; and surgical procedures."

Positive

"There were early and ongoing conversations with these patients about their end of life care as part of their wider treatment and care planning."

Neutral

"The practice ensured that end of life care was delivered in a coordinated way which took into account the needs of different patients including those who may be vulnerable because of their circumstances."

Neutral

"For example: • Patients receiving end of life care carers those at risk of developing a longterm condition and those requiring advice on their diet smoking and alcohol cessation."

Positive

"• A programme of clinical audit was used to monitor quality and to make improvements."

Positive

"This included ongoing support onetoone meetings coaching and mentoring clinical supervision and facilitation and support for revalidating GPs and nurses."

Neutral

"This covered such topics as safeguarding infection prevention and control fire safety health and safety and confidentiality."

Positive

"• Ensure policies and protocols are in place and up to date to assist staff with significant event reporting infection control the secure storage and monitoring of prescriptions repeat prescribing health and safety and referrals."

Positive

"• Some risks to patients had been assessed however improvements were required to risks relating to recruitment training health and safety fire safety and infection control."

Positive

"Policies or protocols were not in place or were not updated for significant event reporting infection control the secure storage and monitoring of prescriptions repeat prescribing health and safety or referrals."

Positive

"This identified possible risks across the practice and covered topics such as health and safety infection control communication practice protocols and prescribing."

Neutral

"For example those relating to recruitment training health and safety fire safety and infection control."

Positive

"• A practice nurse and health care assistant were the infection prevention and control IPC clinical leads who liaised with the local infection prevention teams to keep up to date with best practice."

Positive

"However there were systemic weaknesses in governance systems relating to infection prevention and control emergency medicines monitoring patients on warfarin uncollected repeat prescriptions and monitoring fridge temperatures."

Positive

"• The practice had a variety of other risk assessments to monitor safety of the premises such as infection prevention and control and legionella Legionella is a term for a particular bacterium which can contaminate water systems in buildings."

Positive

"• There were premisesrelated concerns contributing to poor maintenance and infection prevention and control processes."

Positive

"The standards for infection prevention and control in the practice required improvement."

Positive

"For example diabetes prescribing safeguarding infection prevention and control information governance commissioning and the Quality and Outcomes Framework QOF."

Positive

"• Staff received training that included: safeguarding fire safety awareness basic life support mental capacity act chaperoning infection prevention and control and information governance."

Neutral

"This covered such topics as safeguarding infection prevention and control fire safety health and safety and confidentiality."

Positive

"We also noted cleaning equipment in the cleaner’s cupboard was not stored appropriately as per advice given in the audit."

Neutral

"• The practice made use of an external cleaning company and cleaning schedules were in place."

Neutral

"For example the practice had created a schedule of cleaning and decontaminating medical equipment however only one clinical staff member was completing this record."

Neutral

"In particular: • The practice schedule for cleaning and decontaminating medical equipment was not being completed by all clinical staff."

Positive

"The CCT also worked closely with a wellbeing officer who contributed to the health and social care of elderly patients."

Positive

"• Longer appointments were available for patients with a learning disability chronic conditions complex needs a new cancer diagnosis elderly and families experiencing bereavement."

Positive

"Following our inspection we were informed that the practice had updated their emergency medicine stock."

Positive

"We found a repeat prescription for warfarin a medicine that stops blood clotting had been issued without any records of a recent blood test."

Neutral

"• We were told the medicine fridge temperatures were checked daily by the nursing team."

Positive

"The chair of the PPG also represented the practice at network meetings which looked at the structure and implementation of health and social care initiatives within the locality."