What is the Quality of Safety at KS Medical Centre Limited

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."

Neutral

"For example: • Patients receiving end of life care those at risk of developing a longterm condition and those requiring advice on their diet and smoking were signposted to the relevant service."

Positive

"For example the emergency alarm cord in the toilet had not been changed and additional signage alerts for oxygen storage had not been displayed as recommended."

Positive

"This inspection was carried out to review 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

"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

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

Positive

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

Positive

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

Neutral

"For example whilst there was evidence that carpets in consultation rooms had recently been cleaned and privacy curtains changed immediately prior to the inspection we could not determine the frequency of these tasks or when they had previously been undertaken."

Positive

"• The practice had a variety of other risk assessments 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

"The practice had systems for being aware of notifiable safety incidents and sharing the information with staff and ensuring appropriate action was taken."

Positive

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

Positive

"• We reviewed safety records incident reports patient safety alerts and minutes of meetings where significant events were discussed."

Positive

"The arrangements for managing medicines including emergency medicines and vaccines in the practice minimised risks to patient safety including obtaining prescribing recording handling storing security and disposal."

Positive

"This included support training for all staff on communicating with patients about notifiable safety incidents."

Positive

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

Positive

"Overview of safety systems and processes The practice had clearly defined and embedded systems processes and practices in place to minimise risks to patient safety."

Positive

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

Neutral

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

Positive

"• A health and safety risk assessment including fire risk had been completed but not all risks identified had been actioned."

Positive

"There was some evidence to support that lessons were shared and action was taken to improve safety in the practice."

Positive

"The areas where the provider should make improvement are; • Establish a comprehensive recording system for the receipt dissemination and response to safety alerts received by the practice."

Positive

"Overview of safety systems and processes The practice had some clearly defined and embedded systems processes and practices in place to keep patients safe and safeguarded from abuse which included: • Arrangements were in place to safeguard children and vulnerable adults from abuse."

Positive

"Our key findings across all the areas we inspected were as follows: • There was an open and transparent approach to safety and a system in place for reporting and recording significant events although records of analysis and learning from significant events were limited in detail."

Positive

"The areas where the provider must make improvement are; • Take action to address identified concerns with health and safety and fire safety processes."

Positive

"For example the practice had not fully implemented all fire safety recommendations following an external health and safety risk assessment."

Positive

"• We reviewed safety records incident reports patient safety alerts and minutes of meetings."

Positive

"There was a health and safety policy available with a poster in the reception office which identified local health and safety representatives however those named included previous practice staff members."

Positive

"There was no evidence of fire safety or Infection and prevention control training."

Positive

"The practice had not fully implemented all fire safety recommendations following an external health and safety risk assessment."

Positive

"• Risks to patients were assessed and generally wellmanaged apart from those relating to health and safety infection control and recruitment checks."

Positive

"• Ensure that staff attend basic life support training at intervals in accordance with national guidance and undertake infection control and fire safety training as part of a mandatory training programme."

Positive

"We were told that medical and safety alerts when received were routinely circulated to relevant staff discussed at clinical practice team meetings and acted upon where necessary."

Positive

"The practice had other risk assessments in place to monitor safety of the premises such as infection control and legionella."

Positive

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

Neutral

"Systems and processes to address identified risks were not implemented well enough to ensure patients were kept safe for example infection control health and safety fire safety and Disclosure and Barring Service checks."

Positive

"• Staff interviewed knew how to recognise signs of abuse in children young people and adults whose circumstances may make them vulnerable."

Positive

"• Staff were able to recognise the signs of abuse in older patients and knew how to escalate any concerns."

Positive

"Overview of safety systems and processes The practice had some clearly defined and embedded systems processes and practices in place to keep patients safe and safeguarded from abuse which included: • Arrangements were in place to safeguard children and vulnerable adults from abuse."

Positive

"• The practice had a variety of other risk assessments 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

"• Risks to patients were assessed and generally wellmanaged apart from those relating to health and safety infection control and recruitment checks."

Positive

"• Ensure that staff attend basic life support training at intervals in accordance with national guidance and undertake infection control and fire safety training as part of a mandatory training programme."

Positive

"• The practice had an infection control policy and had conducted an internal infection control audit however there were no documented action plans to address issues identified."

Positive

"The practice had other risk assessments in place to monitor safety of the premises such as infection control and legionella."

Positive

"An internal infection control had been conducted in the last year but there was no documentation of an action log and timeline or when actions had been taken."

Neutral

"There was an infection control protocol in place and one of the practice nurses was the infection control clinical lead."

Neutral

"Systems and processes to address identified risks were not implemented well enough to ensure patients were kept safe for example infection control health and safety fire safety and Disclosure and Barring Service checks."

Positive

"Kindness dignity respect and compassion During our inspection we observed that members of staff were courteous and very helpful to patients and treated them with dignity and respect."

Positive

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

Positive

"• Survey information we reviewed showed that patients said they were treated with compassion dignity and respect and they were involved in decisions about their care and treatment."

Positive

"• However results from the national GP patient survey showed patients had responded not so well on questions relating to compassion dignity and respect."

Positive

"However patients had not responded so well in the GP patient survey for responses relating to compassion dignity and respect."

Positive

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

Positive

"• Patients said they felt the practice offered a good service and staff were helpful polite caring and treated them with dignity and respect."

Positive

"• Patients said they felt the practice offered a very good service and staff were helpful polite caring and treated them with dignity and respect."

Positive

"Patients said they felt the practice offered a very good service and staff were helpful polite caring and treated them with dignity and respect."

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

"For example the practice were working with secondary care to improve the process of referrals after receiving a complaint from a patient whose care was delayed by a local hospital."

Positive

"For example following a complaint about issues with registering for online services to book appointments the practice manager provided training to four members of administration staff to address knowledge shortfalls."

Positive

"• An overarching governance framework supported the delivery of the strategy and good quality care."

Positive

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

Neutral

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

Positive

"Governance arrangements The practice had a limited formal governance framework which supported the delivery of the strategy and good quality care."

Positive

"• Ensure effective governance systems for assessing and monitoring the quality of service provision."

Positive

"Including comprehensive policies and procedures programme of quality improvement and records of outcomes and learning."

Positive

"There was evidence of quality improvement including clinical audit."

Positive

"• Ensure effective governance systems for assessing and monitoring the quality of service provision."