What is the Quality of Safety at Modality Darlaston Practice

Positive

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

Positive

"At this inspection we found: • Staff involved and treated patients with compassion kindness dignity and respect."

Positive

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

Positive

"• Staff were clear on their roles and accountabilities including in respect of safeguarding and infection prevention and control although not all staff were aware which GP was the safeguarding lead."

Positive

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

"Results from the national GP patient survey showed patients gave mixed responses to questions relating to if patients felt they were treated with compassion dignity and respect."

Positive

"• During the inspection 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

"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

"The practice had reviewed the results and identified that improvements needed to be made The practice respected patients’ privacy and dignity."

Positive

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

Positive

"Track record on safety The practice had a good track record on safety."

Positive

"Some of the staff had received uptodate safeguarding and safety training appropriate to their role."

Positive

"• The practice manager did not have any knowledge of the monthly drug safety updates and know that these were received centrally and sent to the practice to action where appropriate."

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

"Risks to patients Although there were systems to assess monitor and manage risks to patient safety a number of these needed to be strengthened."

Positive

"• There were comprehensive risk assessments in relation to safety issues."

Positive

"• The practice monitored and reviewed safety using information from a range of sources."

Positive

"We also identified that the practice was not receiving the monthly drug safety updates."

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 recording and responding to safety incidents and sharing information with staff to ensure appropriate action was taken."

Positive

"• The practice had clearly defined and embedded systems to minimise risks to patient safety this included an effective process for monitoring and actioning safety alerts."

Positive

"• The practice had clearly defined and embedded systems and processes to minimise risks to patient safety and had an effective process in place for monitoring and actioning safety alerts."

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 proactively worked with the Clinical Commissioning Group CCG medicines management team to ensure compliance with relevant safety alerts."

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 and regular risk assessments were carried out."

Neutral

"Staff we spoke with were able to explain processes in place to minimise risks to patient safety this included systems in place to ensure compliance with alerts received from central alerting system CAS and alerts from the Medicines and Healthcare products Regulatory Agency MHRA."

Neutral

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

Positive

"• Staff took steps including working with other agencies to protect patients from abuse neglect 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 they were not fully embedded."

Positive

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

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 actively promoted equality and diversity."

Neutral

"Staff had received equality and diversity training."

Positive

"The practice had not sent an acknowledgement letter to the complainant investigated the complaint in accordance with their policy or included the relevant details in the final letter."

Positive

"The practice had not discussed the complaint or any subsequent learning as the patient had left the practice."

Positive

"However not all incidents had been recognised and recorded and the complaint records seen did not comply with the practice policy."

Positive

"There was nothing in the letter about the action the practice planned to take to address these concerns or where the complainant could take their complaint if they weren’t happy with the practices response."

Positive

"• Establish effective systems and processes to ensure good governance with the fundamental standards of care."

Positive

"Governance arrangements The new management structure had introduced clear responsibilities roles and systems of accountability to support good governance and management."

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."

Positive

"The practice had a well established governance framework to support the delivery of safe and effective care."

Positive

"Staff explained by joining a larger group of practices they received support to manage their governance arrangements and as a result systems and processes had been strengthened."

Neutral

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

Positive

"• There was some evidence of discussions regarding sustainability as the practice was now part of large provider but little evidence of action to address future know staffing shortages through staff leaving."

Positive

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

Positive

"• Clinical audits demonstrated quality improvement and the practice carried out regular audits to monitor patient outcomes."

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."