What is the Quality of Facilities at South Wigston Health Centre

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."

Positive

"• A new practice nurse was due to start the day of the inspection which would then give the practice three part time practice nurses and three health care assistants."

Neutral

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

Positive

"We discussed with the practice manager GP and nurse how NICE guidance was received into the practice."

Positive

"The practice were also in the process of recruiting a practice nurse which would alleviate the pressure on the health care assistants."

Positive

"A practice nurse had responsibility for following up patients who did not attend."

Positive

"The areas where the provider must make improvements are: • Implement governance arrangements to ensure appropriate systems are in place for assessing and monitoring the quality of services provided."

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

"• Ensure there are formal governance arrangements in place including systems for assessing and monitoring risks and the quality of the service provision."

Positive

"The system in place for the management of high risk medicines such as warfarin methotrexate and other disease modifying drugs which included regular monitoring in accordance with national guidance was effective."

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

"For example maintenance of the cold chain and review of temperature monitoring of the refrigerators used to store vaccines patient specific directions and some areas of infection control."

Neutral

"For example maintenance of the cold chain and review of temperature monitoring of the refrigerators used to store vaccines authorisations for staff to administer medicines and some areas of infection control."

Neutral

"For example maintenance of the cold chain and review of temperature monitoring of the refrigerators used to store vaccines some areas of infection control and authorisations to administer some medication."

Positive

"Management monitoring and improving outcomes for people Information about people’s care and treatment and their outcomes was routinely collected and monitored and this information used to improve care."

Positive

"Learning and improvement from safety incidents The practice did not have a clear or robust system for reporting recording and monitoring significant events."

Positive

"The practice did not have a clear or robust system for reporting recording and monitoring significant events."

Positive

"There was a system in place for the management of high risk medicines such as warfarin methotrexate and other disease modifying drugs which included regular monitoring in accordance with national guidance."

Positive

"Staff across the practice had key roles in monitoring and improving outcomes for patients."

Positive

"However there were areas in which leadership was less clear such as the monitoring of risks and monitoring of service provision for example lack of robust systems in place for management of risk maintenance of equipment and staff appraisals."

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

"• Quality improvement including clinical audit took place but we saw limited evidence of discussion and wider learning shared with all clinical staff."

Positive

"There was no evidence of completed clinical audit cycles or that audit was driving improvement in performance to improve patient outcomes."

Neutral

"Only one was a completed clinical audit for example minor operations audit."

Positive

"For example the prescribing of a medicine for neuropathic pain."

Positive

"Medicines management We checked medicines stored in the treatment rooms and medicine refrigerators and found they were stored securely and were only accessible to authorised staff."

Positive

"The practice had palliative care meetings."

Positive

"Multidisciplinary palliative care meetings were held every two months."

Positive

"These meetings were attended by district nurses social workers palliative care nurses and decisions about care planning were documented in a shared care record."

Positive

"The practice had a palliative care register and had regular internal as well as multidisciplinary meetings to discuss the care and support needs of patients and their families."

Positive

"For example those with multiple long term conditions mental health problems people from vulnerable groups those with end of life care needs or children on the at risk register."

Positive

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

Positive

"We saw a reception training schedule which covered a number of areas including health and safety office tasks and information governance."

Neutral

"The practice had an online training programme which had role specific training which covered such topics as safeguarding infection prevention and control fire safety health and safety and confidentiality."

Positive

"They had not ensured that they were aware of any potential risks to patients staff and visitors and planned any mitigating actions to reduce the possibility of harm for example general health and safety business continuity fire safety legionella and location of emergency equipment and medicines."

Neutral

"The practice had an online training programme which had role specific training which covered such topics as safeguarding infection prevention and control fire safety health and safety and confidentiality."

Neutral

"The practice infection prevention and control policy had been updated in line with recommendations from the CCG."

Neutral

"Spot checks of cleaning were carried out by the external cleaning company but the practice did not undertake any themselves."

Positive

"The registered person did not have a system in place to ensure an appropriate standard of cleanliness and infection control for example checks on cleaning standards and infection control audits."

Positive

"The contract for cleaning the health centre was the responsibility of a single external company."

Neutral

"We saw there were cleaning schedules kept by the external cleaning company."

Neutral

"South Wigston Health Centre had not carried out any infection control audits to identify any improvements or actions for the external company which undertook the cleaning in the practice."

Neutral

"All cleaning materials and chemicals were stored securely."

Neutral

"We spoke with the registered manager who told us they would contact the external cleaning company and ask them to review and update the COSHH information."

Neutral

"South Wigston Health Centre had not carried out any infection control audits to identify any improvements or actions for the external company who undertake the cleaning in the practice."

Neutral

"The PRG chair told us they were developing work with the practice to address issues patients had raised."

Positive

"For example emergency routes and exits and the needs of vulnerable people e.g. the elderly young children or those with disabilities."