What is the Quality of Safety at Woodbridge Practice

Positive

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

Positive

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

Positive

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

Positive

"Staff took steps to protect patients from abuse neglect harassment discrimination and breaches of their dignity and respect."

Positive

"We received an action plan the day after the inspection which detailed that action was being taken in respect of this."

Positive

"The practice did not have any information available in respect of identifying sepsis immediate action was taken to address this with relevant flowcharts being downloaded and made available within the practice."

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 confidentiality."

Positive

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

Positive

"– Good As part of our inspection process we also look at the quality of care for specific population groups."

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

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

Neutral

"We saw that some areas had been addressed for example disposable privacy screens in the consulting and treatment rooms."

Positive

"Formal systems and processes in place to assess and monitor the quality and safety of the services provided were not embedded or operating effectively."

Positive

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

Positive

"Track record on safety The practice had some safe systems in place • There were comprehensive risk assessments in relation to safety issues."

Positive

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

Positive

"• The practice monitored and reviewed activity however this needed to be strengthened to give an understanding of risks and a clear accurate and current picture that led to safety improvements."

Positive

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

Positive

"• Leaders had established some policies procedures and activities to ensure safety but had not assured themselves that they were operating as intended."

Positive

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

Positive

"• The practice conducted safety risk assessments."

Positive

"It had a suite of safety policies which were regularly reviewed and communicated to staff."

Positive

"Staff received safety information from the practice as part of their induction and refresher training."

Positive

"• There was a system for receiving and acting on safety alerts and we saw evidence that these had been actioned."

Positive

"For example issues around safety and risk."

Positive

"The GPs told us clinical audits were often linked to NICE guidance and medicines management information safety alerts or as a result of information from the quality and outcomes framework QOF."

Positive

"All staff were fully trained on the system and commented positively about the system’s safety and ease of use."

Positive

"Our key findings across all the areas we inspected were as follows: • Where incidents had been identified relating to safety staff had been made aware of the outcome and action taken where appropriate to keep patients and staff safe."

Positive

"Monitoring safety and responding to risk The practice had systems processes and policies in place to manage and monitor risks to patients staff and visitors to the practice."

Positive

"Learning and improvement from safety incidents The practice had a system in place for reporting recording and monitoring significant events incidents and accidents."

Positive

"These actions included regular performance reviews and where necessary further training was provided to ensure the safety of the practice’s patients Working with colleagues and other services The practice worked with other service providers to meet patient’s needs and manage those of patients with complex needs."

Positive

"For example reported incidents and national patient safety alerts as well as comments and complaints received from patients."

Positive

"National patient safety alerts were disseminated by a variety of methods to practice staff these included meetings online tasks emails or by face to face contact."

Positive

"Reliable safety systems and processes including safeguarding There were arrangements in place to safeguard adults and children from abuse that reflected relevant legislation and local requirements and policies were accessible to all staff."

Positive

"The practice also had a health and safety policy."

Positive

"The assistant practice manager conducted a weekly walk around to check the safety of the environment."

Positive

"Staff took steps to protect patients from abuse neglect harassment discrimination and breaches of their dignity and respect."

Positive

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

Positive

"Reliable safety systems and processes including safeguarding There were arrangements in place to safeguard adults and children from abuse that reflected relevant legislation and local requirements and policies were accessible to all staff."

Positive

"Also that the infection control lead had additional training to support this role."

Positive

"In addition the provider should: • Ensure the infection control policy and audit procedure is improved • Ensure all staff have appropriate policies procedures and guidance to carry out their role."

Positive

"Cleanliness and infection control We observed the premises to be clean and tidy."

Positive

"However the infection control lead had only been appointed the week before the inspection and had not had an opportunity to review the infection control process and undertake or review previous audits."

Positive

"It was unclear if all staff received infection control training or induction specific to their role or annual updates."

Neutral

"The infection control policy was not up to date and the infection control audit did not provide detail of when identified areas would be addressed."

Neutral

"We saw there were cleaning schedules in place and cleaning records were kept The practice had a lead for infection control who had undertaken further training to enable them to provide advice on the practice infection control policy and carry out staff training."

Neutral

"The infection control policy was not up to date."

Neutral

"We saw evidence that infection control audits had been carried out in the practice previously."

Neutral

"Staff were able to describe how they would use these to maintain infection control within the practice."

Neutral

"For example there was a lead GP and nurse for infection control and another GP was the lead for safeguarding."

Neutral

"• Staff communicated with patients in a way that they could understand for example directional signage within the practice."

Positive

"• The practice actively promoted equality and diversity."

Neutral

"Staff had received equality and diversity training."

Positive

"The staff we spoke with were very aware of the importance of equality and diversity."

Positive

"Tackling inequity and promoting equality The practice had recognised the needs of different groups in the planning of its services."

Neutral

"The practice provided equality and diversity training for staff."

Positive

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

Positive

"• Information about how to make a complaint or raise concerns was available and it was easy to use."

Positive

"None of the patients we spoke with had ever needed to make a complaint about the practice."

Positive

"• Structures processes and systems to support good governance and management were not always effective."

Positive

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

Positive

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

Positive

"• There was a lack of clear responsibilities roles and systems of accountability to support good governance and management."

Neutral

"• The practice did not hold governance meeting which would have assured them of quality and risks."

Neutral

"The practice regularly submitted governance and performance data to the CCG."

Positive

"Monitoring care and treatment The practice had a comprehensive programme of quality improvement activity and routinely reviewed the effectiveness and appropriateness of the care provided."

Positive

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

Positive

"They spoke positively about the culture in the practice around audit and quality improvement There was a protocol for repeat prescribing which was in line with national guidance."

Positive

"The plan reviewed progress and achievement in improving health outcomes for patients and improving the performance and sustainability of the practice over the next three years."