What is the Quality of Safety at The Cedars Surgery

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

"A governance arrangement supported the delivery of the strategy and good quality care."

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

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

Positive

"• A governance arrangement supported the delivery of the strategy and good quality care."

Positive

"Governance arrangements The practice had a governance framework which supported the delivery of good quality care."

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 governance arrangements did not ensure they were implemented effectively."

Neutral

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

Positive

"• Arrangements for quality improvement such as clinical auditing were in place; and we saw that arrangements for home visit requests and support for military veterans had been reviewed and were effective."

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

"• Arrangements for quality improvement such as clinical auditing were in place; and we saw examples that had resulted in improvements in patient care."

Positive

"• Arrangements for quality improvement including clinical auditing were in place; and we saw examples of improvements in patient care."

Positive

"• Arrangements for quality improvement such as clinical auditing were in place."

Positive

"• no evidence that demonstrated quality improvement from clinical audits."

Positive

"• Review the arrangements for quality improvement such as clinical auditing."

Positive

"There was no evidence of quality improvement resulting from clinical audit: • There had been three clinical audits completed in the last two years."

Positive

"However there was no evidence that demonstrated quality improvement from these audits."

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

"• 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

"The practice had a variety of risk assessments in place 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

"• 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

"We saw evidence that lessons were shared and action was taken to improve safety in the practice."

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

"We saw records of fire drills that had been carried out; and that all staff had received fire safety training."

Positive

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

Positive

"• Arrangements had been reviewed to ensure all MHRA Medicines and Healthcare products Regulatory Agency safety alerts are recorded and addressed."

Positive

"Arrangements had been reviewed to ensure all MHRA Medicines and Healthcare products Regulatory Agency safety alerts are recorded and addressed."

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

"• Visited both sites from which services are provided and reviewed arrangements for fire safety and the security of patient records."

Positive

"However twelve staff had not received annual training in basic life support and thirteen had not received fire safety training."

Positive

"However we found that not all staff had received training in safeguarding fire safety awareness and basic life support."

Positive

"For example twelve staff had no record of current basic life support training and thirteen staff had no record of fire safety training."

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."

Positive

"The practice had a variety of other risk assessments in place 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 notifiable safety incidents and ensured this information was shared with staff to ensure appropriate action was taken."

Positive

"Our key findings across all the areas we inspected were as follows: • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events."

Positive

"• Lessons were shared to make sure action was taken to improve safety in the practice."

Positive

"We saw evidence that lessons were shared and action was taken to improve safety in the practice."

Positive

"This included support training for all staff on communicating with patients about notifiable safety incidents."

Positive

"• The practice utilises the Map of Medicine system to access up to date clinical pathways and make referrals; and we saw evidence of monthly safety searches for high risk medication such as disease modifying antirheumatic drugs DMARDS."

Positive

"• Review arrangements to ensure all MHRA Medicines and Healthcare products Regulatory Agency safety alerts are recorded and addressed."

Positive

"• We saw evidence of monthly safety searches for high risk medication such as disease modifying antirheumatic drugs DMARDS."

Positive

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

Positive

"For example we saw evidence of monthly safety searches for high risk medication such as disease modifying antirheumatic drugs DMARDS."

Positive

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

Positive

"We saw evidence of monthly safety searches for high risk medication such as disease modifying antirheumatic drugs DMARDS."

Positive

"• The practice utilised the Map of Medicine system to access up to date clinical pathways and produce referral documents automatically populated with patient details; and we saw evidence of monthly safety searches for high risk medication such as disease modifying antirheumatic drugs DMARDS."

Positive

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

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

"Overview of safety systems and processes The practice did not have fully effective systems processes and practices in place to keep patients safe and safeguarded from abuse."

Positive

"However twelve staff had not received annual training in basic life support and thirteen had not received fire safety training."

Positive

"For example twelve staff had no record of current basic life support training and thirteen staff had no record of fire safety training."

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

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

Positive

"• Staff were able to recognise the signs of abuse in older people and knew how to escalate any concerns."

Positive

"For example the practice participated in Gemini scheme an independent local scheme to develop existing domestic abuse accommodation support and training for women men and children to support patients experiencing domestic abuse."

Positive

"The practice had a variety of risk assessments in place 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."

Neutral

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

Neutral

"An annual infection control audit had been carried out for the Cedars Surgery and we saw evidence that action was taken to address any improvements identified as a result."

Positive

"The practice had a variety of other risk assessments in place 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 nurse was the infection control clinical lead who liaised with the local infection prevention teams to keep up to date with best practice."

Neutral

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

Neutral

"An annual infection control audit had been carried out for the Cedars Surgery and we saw evidence that action was taken to address any improvements identified as a result."

Positive

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

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

"They told us they were treated with respect staff were helpful and friendly and that the practice was clean and tidy."

Positive

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

Positive

"• 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

"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."