What is the Quality of Facilities at The Cedars Surgery

Positive

"We saw a record showing the nurse with lead responsibility for IPC had completed refresher training; that cleaning schedules were in place; and evidence that IPC was discussed at the fortnightly meetings of the nursing team."

Positive

"We saw that the clinical appointment system included daily slots to record requests for home visits and these were reviewed by a GP or advanced nurse practitioner each morning."

Positive

"The practice nurse was the infection control clinical lead who liaised with the local infection prevention teams to keep up to date with best practice."

Positive

"• Where a patient’s mental capacity to consent to care or treatment was unclear the GP or practice nurse assessed the patient’s capacity and recorded the outcome of the assessment."

Neutral

"The team included a GP specialist adviser and a practice nurse specialist adviser."

Positive

"• arrangements for monitoring vaccine storage temperatures recording and addressing safety alerts and infection prevention and control were not implemented effectively."

Positive

"Arrangements for planning and monitoring the number of staff and mix of staff needed to meet patients’ needs required improvement."

Positive

"We found gaps in the authorisation for vaccines before they were provided to patients; monitoring of vaccine fridge temperatures; in the monitoring and response to safety alerts; in the arrangements for clinical supervision of some staff; and in the security of blank prescription paper."

Positive

"However we found gaps in the assessment and monitoring of risk including in the security of patient records and blank prescription paper; arrangements for monitoring vaccine storage temperatures; for monitoring safety alerts; and for infection prevention and control."

Positive

"However we found gaps in the assessment and monitoring of risk; and governance arrangements did not ensure all policies and procedures had been implemented effectively."

Neutral

"It is based on a combination of what we found when we inspected information from our ongoing monitoring of data about services and information given to us from the provider patients the public and other organisations."

Positive

"For example the arrangements for monitoring and recording had not ensured all staff had received appropriate supervisory support; or up to date training in basic life support safeguarding and fire safety."

Positive

"Management monitoring and improving outcomes for people The practice used the information collected for the Quality and Outcomes Framework QOF and performance against national screening programmes to monitor outcomes for patients."

Positive

"However we found that the system for monitoring safety alerts was not implemented well enough to keep patients safe."

Positive

"We found gaps in the monitoring of vaccine fridge temperatures; in the monitoring and response to safety alerts; in the arrangements for clinical supervision of some staff; and in the security of blank prescription paper."

Positive

"However we found gaps in the assessment and monitoring of risk; and there was no evidence that demonstrated quality improvement."

Positive

"• There were procedures in place for monitoring and managing risks to patient and staff safety."

Positive

"However we found gaps in the assessment and monitoring of risk; and governance arrangements did not ensure all policies and procedures had been implemented effectively."

Positive

"However the leadership and culture for oversight monitoring and assessing risk were not always implemented well enough to keep patients safe."

Neutral

"It is based on a combination of what we found when we inspected information from our ongoing monitoring of data about services and information given to us from the provider patients the public and other organisations."

Neutral

"• The practice had a system for monitoring repeat prescribing for people receiving medication for mental health needs."

Neutral

"• The GPs made regular visits to local residential homes to provide care for patients with a learning disability and to elderly patients for example for those living with dementia."

Positive

"• GP staffing levels had improved and we saw evidence that the nursing team and have access to clinical support and advice should a medical emergency arise during the practice opening hours."

Positive

"We found gaps in the authorisation for vaccines before they were provided to patients; monitoring of vaccine fridge temperatures; in the monitoring and response to safety alerts; in the arrangements for clinical supervision of some staff; and in the security of blank prescription paper."

Positive

"This included ongoing support onetoone meetings coaching and mentoring clinical supervision and facilitation and support for revalidating GPs."

Positive

"We found gaps in the monitoring of vaccine fridge temperatures; in the monitoring and response to safety alerts; in the arrangements for clinical supervision of some staff; and in the security of blank prescription paper."

Positive

"For example no fire risk assessments or regular fire drills had been carried out for either practice; and there was no audit of infection prevention and control for the Village Surgery."

Positive

"• Looked at records and information including that relating to staff recruitment checks and training infection prevention and control safety alerts storage of and authorisations for vaccinations patient consent quality improvement and business planning."

Positive

"• Personnel files had been reviewed and updated to include records of all appropriate recruitment checks undertaken prior to employment • Arrangements for temperature checks of vaccine storage; recorded and addressing safety alerts; and infection prevention and control had been reviewed and we saw evidence of effective implementation."

Positive

"• Arrangements for temperature checks of vaccine storage; recorded and addressing safety alerts; and infection prevention and control had been reviewed and we saw evidence of effective implementation."

Positive

"• arrangements for monitoring vaccine storage temperatures recording and addressing safety alerts and infection prevention and control were not implemented effectively."

Positive

"However there was no evidence of an infection prevention and control audit for the Village Surgery site."

Positive

"For example there was no infection prevention and control audit for the Village Surgery site; and the system for safety alerts had not recorded or addressed six safety alerts regarding drugs and medical devices."

Neutral

"• Arrangements for infection prevention and control IPC had been reviewed an IPC audit had been completed and identified actions had been addressed for both sites."

Neutral

"Arrangements for infection prevention and control IPC had been reviewed an IPC audit had been completed for all sites including the Village Surgery site which is now closed."

Neutral

"Arrangements for infection prevention and control IPC had been reviewed an IPC audit had been completed and identified actions had been addressed for all sites."

Positive

"For example no fire risk assessments or regular fire drills had been carried out for either practice; and there was no audit of infection prevention and control for the Village Surgery."

Positive

"• Ensure that arrangements for infection prevention and control are reviewed recorded and any identified actions are addressed for the Village Surgery site."

Positive

"However there was no evidence of an infection prevention and control audit for the Village Surgery site."

Positive

"For example there was no infection prevention and control audit for the Village Surgery site; and the system for safety alerts had not recorded or addressed six safety alerts regarding drugs and medical devices."

Neutral

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

Positive

"We saw a record showing the nurse with lead responsibility for IPC had completed refresher training; that cleaning schedules were in place; and evidence that IPC was discussed at the fortnightly meetings of the nursing team."

Positive

"For example we saw an alert relating to patients prescribed a medicine for the treatment of osteoporosis where patients had been identified records flagged and appropriate action had been taken and recorded."

Positive

"We saw that palliative care nurses attended clinical meetings."

Positive

"There were early and ongoing conversations with these patients about their end of life care as part of their wider treatment and care planning."

Neutral

"The practice ensured that end of life care was delivered in a coordinated way which took into account the needs of different people including those who may be vulnerable because of their circumstances."

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

"For example for those reviewing patients with longterm conditions we saw evidence of training in advanced asthma care wound care and management and stop smoking support."

Positive

"There was a health and safety policy available with a poster in the reception office which identified local health and safety representatives."

Neutral

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