What is the Quality of Safety at South Wigston Health Centre

Positive

"The practice did not have a robust system in place for the dissemination of safety alerts or to ensure that actions were taken where appropriate."

Positive

"The practice had systems in place for notifiable safety incidents and ensured this information was shared with staff to ensure appropriate action was taken."

Positive

"The practice told us they had a number of ongoing projects to improve patient safety and look at efficient and cost effective prescribing."

Positive

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

Positive

"• One significant event had been reported to the National Reporting and Learning System NRLS which is a central database of patient safety incident reports."

Positive

"One significant event had been reported to the National Reporting and Learning System NRLS which is a central database of patient safety incident reports."

Positive

"• We reviewed safety records incident reports patient safety alerts and found that a new system was in place where all GP partners read and reviewed the alerts."

Positive

"Information about safety was recorded and reviewed although this was not always in depth so that learning could be maximised."

Positive

"For example adult safeguarding fire safety and information governance."

Positive

"We found that the practice did not have processes in place to prioritise safety identify risks and improve patient safety such as a process to learn from significant events near misses or complaints."

Positive

"We saw evidence that maintenance was undertaken as required for example for gas electric and fire safety systems."

Positive

"• The practice had a fire safety policy."

Positive

"Some staff had not had recent fire safety training."

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

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

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."

Positive

"National patient safety alerts were not reviewed by a GP to ensure appropriate action was taken."

Positive

"This meant that we could not be assured that patients were safe and that safety alerts were being managed in a robust and consistent manner."

Positive

"• Identify assess and manage risks relating to the health welfare and safety of patients staff and other people who may be at risk within the practice."

Positive

"Although the practice reviewed when things went wrong investigations were not thorough enough and lessons learned were not communicated and so safety was not improved."

Positive

"We found that clinical safety alerts were assessed by a nonclinical member of staff who determined if the information required clinical action."

Positive

"The GPs told us clinical audits were often linked to medicines management information safety alerts or as a result of information from the quality and outcomes framework QOF."

Positive

"Providers should use risk assessments about the health safety and welfare of people who sue their services to make required adjustments."

Positive

"We found there was no GP lead responsible for clinical safety alerts."

Positive

"The practice had a system in place to disseminate national patient safety alerts or Medicines and Healthcare Products Regulatory Agency MHRA alerts to all practice staff."

Positive

"Reliable safety systems and processes including safeguarding The practice had systems to manage and review risks to vulnerable children young people and adults."

Positive

"We saw evidence that maintenance was undertaken as required for example for gas electric and fire safety systems."

Neutral

"The safety alert policy identified two key people to receive alerts."

Neutral

"Monitoring safety and responding to risk The practice was located in a health centre that was shared with other services and was maintained by NHS property services."

Positive

"• Patients we spoke with said they were treated with compassion dignity and respect and they were involved in decisions about their care and treatment."

Positive

"• Patients were positive about their interactions with staff and said they were treated with compassion dignity and respect."

Positive

"They also 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

"We issued a requirement notice in respect of these issues."

Positive

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

Neutral

"However further work was required in respect some areas of infection control and the management of risk to patients who are registered with the practice."

Positive

"• Patients said they were treated with compassion dignity and respect and they were involved in their care and decisions about their treatment."

Positive

"The evidence from all these sources showed patients were satisfied with how they were treated and that this was with compassion dignity and respect."

Positive

"Patientcarer support to cope emotionally with care and treatment The national patient survey information we reviewed showed patients were positive about the emotional support provided by the practice and rated it well in this area."

Positive

"The majority of patients said they were treated with compassion dignity and respect."

Positive

"We also saw that staff treated patients with kindness and respect and maintained confidentiality."

Positive

"Disposable curtains were provided in consulting rooms and treatment rooms so that patients’ privacy and dignity was maintained during examinations investigations and treatments."

Positive

"• The governance framework currently in place to support the delivery of strategy and good quality care need to be reviewed."

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

"However some governance processes still required improvement and some were not always adhered to."

Positive

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

Positive

"Governance arrangements The governance arrangements in place at the time of our inspection had not ensured risk assessments had been carried out in the areas of South Wigston Health Centre used by practice."

Neutral

"The practice did not hold regular governance meetings and issues were discussed at ad hoc meetings."

Neutral

"The practice did not hold monthly staff meetings where governance issues where performance quality and risks had been discussed."

Neutral

"This included governance arrangements such as policies and procedures."

Positive

"This report describes our judgement of the quality of care at this service."

Positive

"They all felt that the quality of care was very good They felt respected well looked after and staff were kind and considerate."

Positive

"They all felt that the quality of care was very good."

Positive

"This report describes our judgement of the quality of care at this service."

Positive

"They also 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

"Disposable curtains were provided in consulting rooms and treatment rooms so that patients’ privacy and dignity was maintained during examinations investigations and treatments."

Neutral

"These ensured that patients had privacy when being examined."

Neutral

"Staff and patients told us that all consultations and treatments were carried out in the privacy of a consulting room."

Positive

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

Positive

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

Positive

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

Positive

"• Systems and processes in place in regard to infection control were now effective."

Neutral

"However further work was required in respect some areas of infection control and the management of risk to patients who are registered with the practice."

Neutral

"A GP was the infection control clinical lead."

Neutral

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

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

"For example risk assessments for legionella general office environment disclosure and barring DBS and control of substances hazardous to health COSHH infection control and fire safety."

Positive

"For example risk assessments for legionella legionella water checks general office environment disclosure and barring DBS and control of substances hazardous to health COSHH infection control and fire safety."

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

"We were not assured that this was comprehensive enough to enable him to provide advice on the practice infection control policy and carry out staff training."

Positive

"An infection control policy and supporting procedures were available for staff to refer to which enabled them to plan and implement measures to control infection."

Positive

"For example significant events infection control cold chain needlestick injury and legionella."

Neutral

"Cleanliness and infection control The property in which South Wigston Health Centre occupied a number of rooms was owned by NHS Property Services."

Neutral

"We spoke with the infection control lead."

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

"Minutes of practice meetings we looked at did not show that infection control was discussed."

Neutral

"For example there was a lead GP for infection control and two GP partners were the leads for safeguarding."

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."

Positive

"The registered person must ensure that any complaint received must be investigated and necessary and proportionate action must be taken in response to any failure identified by the complaint or investigation."

Positive

"None of the patients we spoke with had ever needed to make a complaint about the practice."

Positive

"We spoke with the management team who advised us they would ensure that information about how to make a complaint was readily available."

Positive

"There was evidence of quality improvement including clinical audit."

Positive

"The health visitor was available in the practice every morning for a limited amount of time."

Positive

"We were shown the electronic staff handbook that was available to all staff which included sections on equality and harassment and bullying at work."

Positive

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

Neutral

"The practice provided equality and diversity training through elearning."

Neutral

"Staff we spoke with and elearning records we looked at confirmed that they had completed equality and diversity training in the last two years."