What is the Quality of Safety at Orchard Surgery - St Ives

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

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

Positive

"• The overarching governance framework to support the delivery of the strategy and good quality care including arrangements to monitor and improve quality and identify risk had been significantly improved."

Positive

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

Positive

"• Information governance had been improved and practice staff were able to use the computer system to provide assurance around patient recall systems consistently code patient groups and produce accurate performance data."

Positive

"• Information governance was poor and practice staff were unable to use the computer system to provide assurance around patient recall systems consistently code patient groups and produce accurate performance data."

Positive

"For example governance arrangements including fire safety and infection control and prevention were inadequate."

Positive

"Governance arrangements The lack of an effective governance structure that provided information and held people to account meant; • The GPs did not have a comprehensive understanding of the clinical performance of the practice."

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 recognises the significant improvements made to the quality of care provided by the 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

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

Positive

"There was no evidence of development plans for the staff members monitoring of performance and quality of care delivered."

Positive

"Where responsibility for the care and treatment of service users was shared with or transferred to other persons the registered person did not ensure that timely care planning took place to ensure the health safety and welfare of those service users."

Positive

"• The practice had systems to manage risk so that safety incidents were less likely to happen."

Positive

"The practice had engaged qualified persons to train and support the staff to undertake a comprehensive fire safety assessment and to implement identified improvements."

Positive

"• A health and safety policy was available which identified staff with responsibility for health and safety within the practice."

Positive

"This included support and training for all staff on communicating with patients about notifiable safety Are services wellled?"

Positive

"• The practice had improved the systems to assess monitor and mitigate risks to patients; For example risk assessments undertaken to ensure the health and safety of patients of receiving the care and treatment."

Positive

"• The practice had reviewed the fire safety policy and key practice staff had attended a training course provided by the local fire safety officers."

Positive

"Qualified persons had supported them in undertaking risk assessments including fire safety and infection control and prevention."

Positive

"• The practice had a system and clear oversight to receive and take action on safety alerts."

Positive

"For example The practice had not assessed the risks to the health and safety of service users receiving care and treatment."

Positive

"• Processes were in place to receive and take action on safety alerts for example those sent from the Medicines and Healthcare Products Regulatory Agency."

Positive

"Monitoring risks to patients The procedures in place for monitoring and managing risks to patient and staff safety had been improved significantly."

Positive

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

Neutral

"Overview of safety systems and process There were practice systems processes and practices in place to ensure patients were kept safe and safeguarded from abuse."

Neutral

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

Positive

"• We reviewed the practice fire safety systems and processes."

Neutral

"Importantly the provider must: • Ensure further improvements to the management of fire safety in the practice."

Positive

"Monitoring risks to patients The procedures in place for monitoring and managing risks to patient and staff safety were inadequate."

Positive

"The practice did not assess monitor and improve the quality and safety of the service provided in the carrying out of the regulated activity."

Positive

"• Ensure that risk assessments for fire safety are undertaken and that any identified actions are completed in a timely manner and formally risk assessing access to the dispensary."

Positive

"• The practice had not followed their own fire safety policy and did not have evidence of any fire risk Are services safe?"

Positive

": Safe care and treatment The practice had not assessed the risks to the health and safety of service users receiving care and treatment."

Positive

"• The practice should improve the systems to assess monitor and mitigate risks to patients for example implement logs for recording safety alerts who received or actions taken and to give oversight to ensure that all staff received the appropriate training for their roles or needs."

Positive

"For example governance arrangements including fire safety and infection control and prevention were inadequate."

Positive

"Areas for improvement Action the service MUST take to improve • The practice must assess the risks to the health and safety of patients of receiving the care and treatment and do all that is reasonably practicable to mitigate any such risks."

Positive

"• A health and safety policy was available which identified staff with responsibility for health and safety within the practice."

Positive

"Immediately following our inspection the practice contacted the Fire Service and enrolled onto a training course which would give them the knowledge and skills to manage fire safety in the practice."

Positive

"• Practice staff had received some training deemed mandatory for example safeguarding of children and vulnerable adults but they had not received training in health and safety equality and diversity and infection control and prevention."

Positive

"The areas where the provider must make improvements are: • The practice must assess the risks to the health and safety of patients of receiving the care and treatment and do all that is reasonably practicable to mitigate any such risks."

Positive

"• The practice did have a system to receive and take action on safety alerts but did not have oversight of these for example a log for recording the alert and detailing any actions and outcomes to ensure future monitoring or shared learning."

Positive

"• Processes were in place to receive and take action on safety alerts for example those sent from the Medicines and Healthcare Products Regulatory Agency."

Positive

"Most practice staff were overdue the annual fire safety refresher training."

Positive

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

Neutral

"Overview of safety systems and processes The practice systems processes and practices in place were not sufficient to ensure patients were kept safe and safeguarded from abuse."

Neutral

"This was intended to cover such topics as safeguarding infection prevention and control fire safety health and safety and confidentiality."

Positive

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

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

"We spoke with four patients they told us they were very satisfied with the care provided by the practice and said their dignity and privacy was respected."

Positive

"• Patients said they were treated with compassion dignity and respect."

Positive

"• We saw that practice staff worked together as a cohesive team and treated patients with kindness and respect and maintained patient and information confidentiality."

Positive

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

Positive

"• Ensure that the new systems and process recently introduced to provide appropriate recall for patients and medical records are maintained to provide accurate complete and contemporaneous record in respect of each patient."

Positive

"• The systems and processes to provide appropriate recall for patients and to ensure medical records are maintained to provide an accurate complete and contemporaneous record in respect of each patient had been recently introduced."

Positive

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

Positive

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

Positive

"Results from the national GP patient survey showed patients felt they were treated with compassion dignity and respect."

Positive

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

Positive

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

Positive

"We spoke with four patients they told us they were very satisfied with the care provided by the practice and said their dignity and privacy was respected."

Positive

"• Curtains or screens 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."

Positive

"• Practice staff we spoke with knew how to recognise signs of abuse in children young people and adults whose circumstances may make them vulnerable."

Positive

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

Positive

"• Practice staff had undertaken additional training in awareness of domestic abuse and female genital mutilation."

Positive

"• Arrangements to safeguard children and vulnerable adults from abuse had been improved and reflected relevant legislation and local requirements."

Positive

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

Positive

"• Arrangements to safeguard children and vulnerable adults from abuse reflected relevant legislation and local requirements."

Positive

"Effective staffing Staff had the skills knowledge and experience to deliver effective care and treatment but not all practice staff had received all the training deemed mandatory such as infection control training."

Positive

"Qualified persons had supported them in undertaking risk assessments including fire safety and infection control and prevention."

Positive

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

Neutral

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

Positive

"• The lead member of staff for infection control in the practice was a nurse who had attended appropriate training to undertake this role."

Neutral

"The practice had liaised with the local infection control nurse who undertook a joint audit of the practice."

Neutral

"The practice nurse had liaised with the local infection control nurse who had attended the practice and undertaken a joint infection control audit."

Positive

"Effective staffing Staff had skills knowledge and experience to deliver effective care and treatment but not all practice staff had received all the training deemed mandatory such as infection control training."

Positive

"For example the practice had not undertaken risk assessments for fire or infection control and prevention."

Positive

"• The practice had not undertaken risk assessments for fire or infection control and prevention."

Positive

"For example governance arrangements including fire safety and infection control and prevention were inadequate."

Positive

"• Practice staff had received some training deemed mandatory for example safeguarding of children and vulnerable adults but they had not received training in health and safety equality and diversity and infection control and prevention."

Positive

"The practice was unable to show that any annual infection control audits had been undertaken."

Positive

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

Neutral

"The practice nurse was named as the infection control clinical lead but they had not received training for this role."

Neutral

"There was an infection control protocol in place but practice staff had not received up to date training."

Positive

"The GPs meet with other health care professionals for example the health visitor and the community care coordinator for unplanned admissions."

Neutral

"A nonclinical staff member who did not have a clinical background and had not received level three safeguarding training met with the health visitor to discuss and transfer information."

Neutral

"• The GPs did not attend the quarterly meeting a staff member who did not hold any clinical qualifications and who had not undertaken level three safeguarding and the health visitor had attended these."

Positive

"Some identified actions had not been completed for example; clear signage in relation to the storage of the oxygen cylinder and the practice did not have clear evacuation plans in place."

Neutral

"However further improvements were needed for example the signage to indicate where the oxygen cylinder was stored needed to be put into place."

Positive

"The practice had not recognised that this complaint should have also been recorded as significant events; they did not show us information to evidence that the learning outcomes had been shared with the practice team and those changes had been made to prevent future incidences happening."

Positive

"Practice staff had undertaken some training deemed mandatory such as safeguarding children and vulnerable adults but not all for example practice staff had not undertaken training in equality and diversity or infection control."

Positive

"• Practice staff had received some training deemed mandatory for example safeguarding of children and vulnerable adults but they had not received training in health and safety equality and diversity and infection control and prevention."

Positive

"• Undertake ongoing quality improvement activities such as clinical audits with suitable follow up to ensure improvements have been achieved."

Positive

"• The practice did not evidence ongoing quality improvement activities such as clinical audits."