What is the Quality of Safety at Silver End Surgery

Positive

"• We were not assured that the practice learned or shared action taken to improve safety when serious incidents or significant events should have been investigated."

Positive

"Track record on safety The practice took steps to maintain the safety of the working environment."

Positive

"• The practice had identified mandatory training for all staff to complete including safeguarding children and adults fire safety and information governance."

Positive

"• The practice took steps to maintain the safety of the working environment."

Positive

"• The practice conducted safety risk assessments."

Positive

"Staff received safety information for the practice as part of their induction and refresher training."

Positive

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

Positive

"• There was an up to date health and safety risk assessment that covered areas including home visits workstation assessments and building."

Positive

"Lessons learned and improvements made The practice did not consistently identify or address safety concerns in a timely manner."

Positive

"• We were not assured that the practice had sufficient arrangements for reviewing and investigating safety incidents and events when things went wrong."

Positive

"• There was a system for receiving and acting on patient safety and medicine alerts."

Neutral

"• There was limited use of systems to record and report safety concerns incidents or near misses."

Positive

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

Positive

"• Patients were supported treated with dignity and respect and were involved as partners in their care."

Positive

"Privacy and dignity The practice respected and promoted patients’ privacy and dignity."

Positive

"• The staff told us that they respected and promoted patients’ privacy and dignity and recognised the importance of this."

Positive

"The areas where the provider must make improvements as they are in breach of regulations are: • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care."

Positive

"• Leadership and governance required strengthening in some areas."

Positive

"Governance arrangements The systems of governance required strengthening."

Neutral

"• There was a corporate process to review key items such as the strategy values objectives plans and governance framework; however this was not being consistently applied at the practice."

Positive

"– Requires Improvement As part of our inspection process we also look at the quality of care for specific population groups."

Positive

"Action was not always taken to improve the quality of care as a result."

Positive

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

Positive

"Privacy and dignity The practice respected and promoted patients’ privacy and dignity."

Positive

"• The staff told us that they respected and promoted patients’ privacy and dignity and recognised the importance of this."

Positive

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

Positive

"• Whilst observations and discussions supported that the practice promoted equality and diversity we saw that only three staff had received equality and diversity training."

Neutral

"Only three staff had received equality and diversity training."

Positive

"• There was no system for identifying complaint trends or identifying actions to prevent reoccurrence."

Positive

"• Information about how to make a complaint or raise concerns was available and it was easy to do."

Positive

"• Some audits had been carried out however there was no programme for regular audits or other quality assurance for the service that would assess monitor and improve the quality of the services provided."

Positive

"• Implement a quality assurance programme that includes undertaking clinical audits."

Positive

"Monitoring care and treatment There was evidence of some quality improvement activity to review the effectiveness and appropriateness of the care Are services effective?"

Positive

"• Limited audit activity had been undertaken and the practice did not have an embedded programme of ongoing clinical audit to drive quality improvement and positively impact patient outcomes."