What is the Quality of Safety at Dr. McCarthy and Partners

Positive

"• There was a formal process in place to monitor that NICE guideline and patient safety alerts were actioned and shared."

Positive

"• Fire safety checks were documented which included for example attendees at the fire evacuation drill."

Positive

"• Implement a formal process to demonstrate how the practice monitored that NICE guidelines and patient safety alerts were actioned."

Positive

"Fire safety checks were documented for example attendees at fire evacuation drills."

Positive

"• Looked at information the practice used to deliver care and treatment such as patient medicine safety alerts."

Neutral

"• Ensure fire safety checks are fully documented."

Positive

"• From the sample of documented examples we reviewed we found there was an effective system for reporting and recording significant events; lessons were shared to make sure action was taken to improve safety in the practice."

Positive

"• Implement a formal process to demonstrate how the practice monitored that NICE guidelines and patient safety alerts were actioned."

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

"• A formal process to demonstrate how the practice monitored that NICE guidelines and patient safety alerts were actioned."

Positive

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

Positive

"The majority of the arrangements in place 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

"• The practice had the majority of systems to minimise risks to patient safety with exceptions."

Positive

"The exceptions included for example; ensuring all chaperones were in receipt of appropriate checks and training completion of a legionella risk assessment and ensuring the systems in place for fire safety checks were fully documented."

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

"• There was a health and safety policy available."

Positive

"The documentation of some of the fire safety checks were inconsistently recorded."

Positive

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

Positive

"• Fire safety checks were not always fully documented."

Neutral

"• Ensure fire safety checks are fully documented."

Neutral

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

Neutral

"• Ensuring the systems in place for fire safety checks were fully documented."

Positive

"Learning and improvement from safety incidents The practice had an effective system in place for reporting recording and reviewing significant events."

Positive

"Monitoring safety and responding to risk There were several systems in place to identify and report risks within the practice such as regular assessments and checks of clinical practice medications equipment and the environment."

Positive

"Equipment used to store current records on all types of media should provide storage that is safe and secure from unauthorised access and which meets health and safety and fire regulations but which also allowed maximum accessibility of the information commensurate with its frequency of use."

Positive

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

Positive

"We saw the practice had a system for managing safety alerts from external agencies."

Positive

"Reliable safety systems and processes including safeguarding The practice had policies in place in relation to safeguarding vulnerable adults and children."

Positive

"Equipment Evidence was kept at the practice to confirm annual safety checks such as for fire extinguishers had been completed."

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 practice complaints policy stated that complaints should be resolved within a relevant period for example six months from the day on which the complaint was received."

Positive

"We saw that complainants had received acknowledgement of the complaint and complaints were investigated and documented in a timely manner as required."

Positive

"None of the patients spoken with had needed to make a complaint about the practice."

Positive

"Areas for improvement Action the service MUST take to improve 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 improvement are: Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care."

Positive

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

Positive

"All staff completed mandatory training which included; information governance IG and confidentiality training."

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

"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

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

Positive

"• Results from the national GP patient survey showed patients were treated with compassion dignity and respect and were involved in their care and decisions about their treatment."

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

"They told us they were satisfied with the care provided by the practice and said their dignity and privacy was respected."

Positive

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

Positive

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

Positive

"We received one comment card which was positive about the standard of care received but negative in respect of reception staff."

Positive

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

Positive

"Patients told us staff were extremely friendly and they were always treated with respect dignity and compassion."

Positive

"There was an open and honest culture and clinical administrative and reception staff all encompassed the concepts of compassion dignity respect and equality."

Positive

"The patients we spoke with told us staff were helpful and treated them with dignity and respect."

Positive

"The patient was immediately referred for specialist attention and advice at a local hospital this was acted on promptly with the patients involvement and understanding with compassion and consideration to the patient’s needs."

Positive

"We saw however that the practice had not followed their policies in respect of a new recruit."

Positive

"Patients said their privacy and dignity was maintained particularly during physical examinations."

Positive

"They told us they were satisfied with the care provided by the practice and said their dignity and privacy was respected."

Positive

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

Positive

"Staff we spoke with were aware of the importance of providing patients with privacy and information was available to help patients understand the care available to them."

Positive

"Patients said their privacy and dignity was maintained particularly during physical examinations."

Neutral

"All patient appointments were conducted in the privacy of a consultation or treatment room."

Neutral

"There were privacy curtains for use during physical and intimate examinations and a chaperone service was available."

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

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

Positive

"The practice manager was already aware of the areas to be addressed such as oversight of staff training infection control audit prior to the inspection and assured us that these areas would be addressed as well as updates to the business continuity plan and fire drills."

Neutral

"Cleanliness and infection control Infection Prevention and Control IPC was monitored within the practice and the policy was available to all staff."

Neutral

"This gave information about aspects of infection control such as the handling of specimens hand washing and the action to be taken following exposure to blood or bodily fluids."

Neutral

"The practice was cleaned in line with infection control guidelines with the cleaners routinely attending every day."

Positive

"There was evidence of quality improvement including clinical audit: Are services effective?"

Positive

"The practice had an ongoing quality improvement plan with the CCG."

Positive

"We found the practice had a number of policies in place aimed at tackling inequity and promoting equality examples included policies regarding equal opportunities and identification of carers."

Positive

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