What is the Quality of Safety at Buttercross Health Centre

Positive

"• There were safe systems in place for fire safety including regular fire drills checks for safe equipment including calibration and mandatory training completion for staff."

Positive

"• Ensure there were safe systems in place for fire safety including regular fire drills checks for safe equipment including calibration and mandatory training completion for staff."

Positive

"Track record on safety The practice did not have a good track record on safety."

Positive

"Not all staff had completed the provider’s mandatory fire safety training and fire drills were not regularly undertaken."

Positive

"Not all staff received uptodate safeguarding and safety training appropriate to their role."

Positive

"However we saw actions from fire safety reports and infection control audits were not fully completed and action plans excluded timeframes."

Positive

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

Positive

"Practice leaders had oversight of safety alerts incidents and complaints."

Positive

"• Ensure there are safe systems in place for fire safety including regular fire drills checks for safe equipment including calibration and mandatory training completion for staff."

Positive

"There was a potential for the safety of patients and staff to be compromised because of gaps in training actions from external fire safety assessments and oversight of infection prevention and control had not been fully implemented."

Positive

"This could result in a risk to patient and staff safety and inaccurate health assessments of patients may occur."

Positive

"• There were comprehensive risk assessments in relation to safety issues except for recommended emergency medicines not held at the practice and dealing with medical emergencies when a GP is not on the premises."

Positive

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

Positive

"However we found concerns regarding fire safety calibration of clinical equipment and infection prevention control."

Positive

"This was because: We found gaps in oversight that needed to be strengthened at the branch surgery such as fire safety and safe storage of medicines."

Positive

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

Positive

"However we were not assured that these were operating as intended in respect of infection prevention and control measures and fire safety particularly at the branch surgery and clinical reviews for patients with long term conditions or those experiencing poor mental health."

Positive

"• In other aspects such as completed information and gaps in oversight regarding staff immunisations medicines safety calibration of equipment and the provider’s mandatory training programme these were still being formalised."

Positive

"In particular: The provider must have safe systems in place for fire safety checks for safe equipment including calibration and infection prevention and control."

Neutral

"At this inspection we found: • The practice had clear systems to manage risk so that safety incidents were less likely to happen."

Neutral

"• The practice regularly assessed the impact of fire safety however actions had not been completed such as Are services safe?"

Positive

"However Symphony Health Services process for complaint management meant that any complaint where people did not wish to take further action resulted in limited investigation and analysis by the practice."

Positive

"• Information about how to make a complaint or raise concerns was available."

Positive

"• The complaint policy and procedures were in line with recognised guidance."

Positive

"• Structures processes and systems to support good governance and management were clearly set out."

Positive

"• The governance and management of joint working arrangements across the provider organisation and with the local area shared services such as the complex care team promoted coordinated personcentred care."

Positive

"The provider had implemented new areas of governance and assessment of the quality of the services provided such as oversight and support although it was too early to show that this was effective."

Positive

"SHS told us they were in the process of establishing and providing administration and governance support including HR maintenance finance and quality assurance processes."

Neutral

"• There were new policies and procedures and a system of governance which needed to have time to be fully implemented and embedded."

Positive

"The areas where the provider should make improvements were: • Continue to implement actions to improve the quality of care outcomes QOF and clinical management of longterm conditions including mental health."

Positive

"The practice continued to implement actions to improve the quality of care outcomes QOF and clinical management of longterm conditions including mental health."

Positive

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

Positive

"• Continue to implement actions to improve the quality of care outcomes QOF and clinical management of long term conditions including mental health."

Positive

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

Positive

"• The practice considered and understood the impact on the quality of care of service changes or developments."

Positive

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

Positive

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

Neutral

"Safety systems and processes The practice had clear systems to keep people safe and safeguarded from abuse however some of these needed improvements."

Positive

"However we saw actions from fire safety reports and infection control audits were not fully completed and action plans excluded timeframes."

Positive

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

Positive

"• Staff involved and treated patients with compassion kindness dignity and respect."

Positive

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

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

"• Staff we spoke to were clear on their roles and accountabilities including in respect of safeguarding and infection prevention and control."

Positive

"However we were not assured that these were operating as intended in respect of infection prevention and control measures and fire safety particularly at the branch surgery and clinical reviews for patients with long term conditions or those experiencing poor mental health."

Positive

"• The practice actively promoted equality and diversity."

Positive

"Not all staff had completed Symphony Health Services mandatory equality and diversity training."

Positive

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

Positive

"SHS told us they were in the process of establishing and providing administration and governance support including HR maintenance finance and quality assurance processes."

Positive

"Exception rates allow practices to achieve quality improvement without being penalised for reasons beyond their control."

Positive

"• The practice was actively involved in quality improvement activity."