What is the Quality of Safety at Higham Ferrers Surgery

Positive

"We found that: • Two medicine safety alerts had not been acted upon which put patients at risk."

Positive

"We rated the practice requires improvement for providing safe services because: • We saw that improvements had been made in relation to prescriptions recruitment procedures and medicine safety alerts but other gaps were identified."

Positive

"In particular in relation to recruitment safety alerts highrisk medicines and prescriptions."

Positive

"• The practice did not have an adequate system in place to safely manage MHRA and other safety alerts."

Positive

"There was evidence of actions taken to support good antimicrobial stewardship which aims to improve the safety and quality of patient care by changing the way antimicrobials are prescribed so it helps slow the emergence of resistance to antimicrobials thus ensuring antimicrobials remain an effective treatment for infection."

Positive

"The practice was rated as requires improvement for providing well led services because: Systems or processes that enabled leaders to assess monitor and improve the quality and safety of the services needed strengthening."

Positive

"• There were no health and safety risk assessments other than those related to control of substances hazardous to health COSHH fire Legionella Legionella is a term for a particular bacterium which can contaminate water systems in buildings electrical safety and equipment calibration."

Positive

"• There were risk assessments in relation to control of substances hazardous to health COSHH Fire Legionella Legionella is a term for a particular bacterium which can contaminate water systems in buildings electrical safety of equipment used within the practice and equipment calibration."

Positive

"• Staff were clear on their roles and accountabilities including in respect of safeguarding and infection prevention and control • Practice leaders had established proper policies procedures and activities to ensure safety and assured themselves that they were operating as intended."

Positive

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

Positive

"• Not all safety systems were operating effectively."

Positive

"All staff received uptodate safeguarding and safety training appropriate to their role."

Positive

"For example there were regular meetings with the health visitor and other concerned professionals to ensure the safety of vulnerable children."

Positive

"Track record on safety We reviewed the practice track record on safety."

Positive

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

Positive

"For example those related to staff recruitment and health and safety needed improvements."

Positive

"• Develop an overview of the status of applicable safety alerts and their implementation status."

Positive

"However we were not shown other health and safety related risk assessments."

Positive

"• The practice had a process in place for managing safety alerts and during our inspection we saw evidence to demonstrate that alerts were acted on where required."

Positive

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

Positive

"• Maintaining a systematic approach to health and safety risk assessments."

Positive

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

Positive

"• The process to identify understand monitor and address current and future risks including risks to patient safety needed strengthening."

Positive

"For example a systematic approach to recruitment determining the skill mix of clinical staff available and health and safety risk assessments was not evident."

Positive

"A systematic approach to health and safety risk assessments was not evident."

Positive

"Where appropriate the alerts were discussed at monthly clinical meetings to ensure that appropriate action was taken and a plan put in place if necessary to ensure patient safety was maintained."

Positive

"• There was a clear system in place for reporting and recording significant events • Lessons were shared to make sure action was taken to improve safety in the practice."

Positive

"• When there were unintended or unexpected safety incidents patients received appropriate support information and a verbal or written apology as appropriate."

Positive

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

Positive

"Our key findings across all the areas we inspected were as follows: • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events."

Positive

"When there were unintended or unexpected safety incidents patients received reasonable support a verbal and written apology and were told about any actions to improve processes to prevent the same thing happening again."

Positive

"There was a health and safety policy available with a poster displayed which identified local health and safety representatives."

Positive

"The practice had systems in place for knowing about notifiable safety incidents When there were unexpected or unintended safety incidents: • The practice gave affected people reasonable support information and a verbal and written apology."

Positive

"National patient safety and medicines alerts were received into the practice by email to the practice manager who cascaded information to relevant staff."

Neutral

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

Positive

"This was with consent from the provider and in line with all data protection and information governance requirements."

Neutral

"These included patients requiring palliative care carers those at risk of developing a longterm condition and those requiring advice on their diet smoking and alcohol cessation."

Positive

"This was with consent from the provider and in line with all data protection and information governance requirements."

Positive

"The areas where the provider must make improvements are: • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care."

Positive

"The areas where the provider must make improvements are: • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care."

Positive

"The areas where the provider must make improvements are: • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care."

Positive

"The lead GP told us that governance arrangements would be strengthened once they were successful in recruiting a further GP and other clinical staff."

Positive

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

Positive

"• There was a clear governance structure which supported the delivery of the strategy and good quality care."

Positive

"Governance arrangements The practice had clear and transparent governance structure which supported the practice in the delivery of the strategy and good quality care."

Neutral

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

Neutral

"Staff received training that included: safeguarding fire procedures and basic life support and information governance awareness."

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 based our judgement on the quality of care at this service is 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

"This recognises the improvements that have been made to the quality of care provided by this service."

Positive

"The quality assurance systems in place to monitor the quality of care and treatment needed strengthening to ensure the service was meeting the fundamental standards."

Positive

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

Positive

"Our judgement of the quality of care at this service is based 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."

Neutral

"We rated the practice as inadequate for providing wellled services because: • The lack of consistent practice management presence was impacting on the quality of care and treatment."

Positive

"Requires improvement 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

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

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

"Kindness respect and compassion Staff treated patients with kindness respect and compassion."

Positive

"• Patients we spoke with told us staff had treated them with compassion kindness dignity and respect."

Positive

"• Comment cards received on the day of our inspection showed patients were treated with kindness respect and compassion."

Positive

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

Positive

"• Staff were clear on their roles and accountabilities including in respect of safeguarding and infection prevention and control • Practice leaders had established proper policies procedures and activities to ensure safety and assured themselves that they were operating as intended."

Positive

"• Staff recognised the importance of people’s dignity and respect."

Positive

"• Staff took steps including working with other agencies to protect patients from abuse neglect harassment discrimination and breaches of their 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

"• We saw staff treated patients with kindness and respect and maintained patient and information confidentiality."

Positive

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

Positive

"The quality assurance systems in place to monitor the quality of care and treatment needed strengthening to ensure the service was meeting the fundamental standards."

Positive

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

Positive

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

Positive

"• The practice in conjunction with a member of the local domestic abuse team offered advice and care to people suffering with domestic abuse one morning each week."

Positive

"• Staff took steps including working with other agencies to protect patients from abuse neglect harassment discrimination and breaches of their dignity and respect."

Positive

"For example there were regular meetings with the health visitor and other concerned professionals to ensure the safety of vulnerable children."

Positive

"• The practice actively promoted equality and diversity."

Positive

"• The complaint policy and procedures were in line with recognised guidance with the exception of the complaint response letter which lacked the escalation details to the Health Service Ombudsman should the complainant remain dissatisfied."

Positive

"• Amend the complaint response letter so it shows the details to escalate to the Health Service Ombudsman should the complainant remain dissatisfied."

Positive

"• The complaint response letter lacked the escalation details to the Health Service Ombudsman should the complainant remain dissatisfied."

Positive

"For example following a complaint that expressed dissatisfaction about a delayed referral for an investigation we saw that the practice had responded to the complainant giving an explanation for the delay."

Positive

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

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 which included where appropriate participation in local and national improvement initiatives."

Positive

"• Governance processes and systems for practice management and quality improvement were not always operating effectively."

Positive

"At present the CCG and NHS England were involved with the practice in quality improvement work including supporting a clinical member of staff."

Positive

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

Neutral

"A GP partner was the infection control lead."

Neutral

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

Neutral

"A formal infection control audit had been undertaken and we saw records of concerns being noted and addressed on a routine basis."