Latest Snippet(s)
Positive
"Privacy and dignity The practice respected patients’ privacy and dignity."
2017-10-05 Snippet(s)
Positive
"• Curtains were provided in consulting rooms to maintain patients’ privacy and dignity during examinations investigations and treatments."
2015-08-20 Snippet(s)
Positive
"Curtains were provided in consulting rooms and treatment rooms so that patients’ privacy and dignity was maintained during examinations investigations and treatments."
Positive
"Staff told us that if they had any concerns or observed any instances of discriminatory behaviour or where patients’ privacy and dignity was not being respected they would raise these with the practice manager."
Neutral
"Staff and patients told us that all consultations and treatments were carried out in the privacy of a consulting room."
Latest Snippet(s)
Positive
"• Staff were clear on their roles and accountabilities including in respect of safeguarding and infection prevention and control • Practice leaders had established proper policies procedures and activities to ensure safety and assured themselves that they were operating as intended."
Positive
"The practice learned and shared lessons identified themes and took action to improve safety in the practice."
Positive
"All staff received uptodate safeguarding and safety training appropriate to their role."
Positive
"• There was a strong emphasis on the safety and wellbeing of all staff."
Positive
"• There was no process or system in place to be assured that appropriate actions were taken in response to medicine safety and devise alerts."
Positive
"Track record on safety • There were comprehensive risk assessments in relation to safety issues."
Positive
"• The practice acted on and learned from external safety events as well as patient and medicine safety alerts."
Positive
"Practice leaders had oversight of national and local safety alerts incidents and complaints."
Positive
"This was because the registered persons had not done all that was reasonably practicable to mitigate risks to the health and safety of service users receiving care and treatment."
Positive
"• Some staff had not been in receipt of regular fire safety training."
Positive
"This helped it to understand risks and gave a clear accurate and current picture of safety that led to safety improvements."
Neutral
"The previous inspection reports can be found by selecting the ‘all reports’ link for Featherstone Family Health Centre on our website at At this inspection we found: • The practice had clear systems to manage risk so that safety incidents were less likely to happen."
2017-10-05 Snippet(s)
Positive
"• The practice had a variety of other risk assessments 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 being aware of notifiable safety incidents and told us they shared the information with staff and to ensure appropriate action was taken."
Positive
"Staff told us lessons were shared to make sure action was taken to improve safety in the practice."
Positive
"• The medical secretary saved medicine safety alerts she had received onto a spreadsheet in the practice shared electronic system."
Positive
"• Introduce a process or system to be assured that appropriate actions are taken in response to medicine safety and devise alerts."
Positive
"• Documented health and safety assessments to demonstrate whether any specific risks related to the practice had been identified appropriate action taken and risk assessments put in place to mitigate the risk."
Positive
"During the inspection the practice manager signed up for the appropriate medicine safety and devise alerts."
Positive
"The arrangements for managing medicines including emergency medicines and vaccines in the practice minimised risks to patient safety including obtaining recording handling storing security and disposal."
Positive
"• A process or system to be assured that appropriate actions were taken in response to medicine safety and devise alerts."
Positive
"This included support training for all staff on communicating with patients about notifiable safety incidents."
Positive
"• Ensure that fire safety training is provided to all staff from induction staff members are in receipt of regular training updates and all staff attend fire drills."
Positive
"• There was no formal process or system to be assured that appropriate actions were taken in response to medicine safety and devise alerts."
Positive
"We reviewed safety records incident reports patient safety alerts."
Positive
"Staff spoken with said that lessons were informally shared between relevant staff and action was taken to improve safety in the practice following complaints or events."
Positive
"• There was no process or system in place to be assured that appropriate actions were taken in response to medicine safety and devise alerts."
Positive
"For example; information governance fire safety and infection prevention and control IPC."
Positive
"The practice had booked training for all staff in fire safety basic life support and defibrillator training and manual handling."
Positive
"For example; the monitoring of high risk medicines medicine safety and devise alerts staff training and refresher oversight recruitment and an inconsistent system applied to reporting recording learning and sharing of incidents and significant events."
Positive
"Medicine safety and devise alerts were received into the practice via email directly to the GPs lead practice nurse and medical secretary."
Positive
"• There was a health and safety policy available."
Positive
"Staff training records demonstrated that not all staff had received fire safety training."
Positive
"• Staff received training that included: safeguarding fire safety awareness basic life support and information governance."
Positive
"• Meeting minutes seen were brief and demonstrated an unstructured approach without regular agenda items such as lessons to be learned and shared following significant events complaints receipt of Medicines and Healthcare products Regulatory Agency MHRA patient safety alerts and whether any action was required or taken."
Positive
"• Had not ensured that staffs were in receipt of regular fire safety training."
Neutral
"The meetings were not structured to contain regular agenda items such as complaints patient safety alerts and significant events for example and the minutes reviewed lacked content."
Neutral
"• Ensured consistency in recording the analysis and outcome of investigations of safety incidents significant events and complaints."
Neutral
"Overview of safety systems and process The practice had the majority of the systems processes and practices in place to minimise risks to patient safety."
Neutral
"This covered such topics as safeguarding infection prevention and control fire safety health and safety and confidentiality."
2015-08-20 Snippet(s)
Positive
"We saw that emergency lighting checks and fire risk assessments that included actions required to maintain safety had been carried out."
Positive
"All staff were fully trained on the system and commented positively about the system’s safety and ease of use."
Positive
"There was regular monitoring of safety to ensure that ways to improve were identified and implemented."
Positive
"Learning and improvement from safety incidents We saw that significant events although not a regular item on the agenda were discussed at practice meetings."
Positive
"Action the provider SHOULD take to improve: • Ensure consistency in recording the analysis and outcome of investigations of safety incidents significant events and complaints."
Positive
"• Document health and safety assessments to demonstrate whether any specific risks related to the practice have been identified appropriate action taken and risk assessments put in place to mitigate the risk."
Positive
"Action the service SHOULD take to improve • Ensure consistency in recording the analysis and outcome of investigations of safety incidents significant events and complaints."
Positive
"Monitoring safety and responding to risk The practice had systems processes and policies in place to manage and monitor risks to patients staff and visitors to the practice."
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
"The practice had a system in place for reporting recording and monitoring significant events incidents accidents and national patient safety alerts as well as comments and complaints received from patients."
Positive
"We found however that some of the safety records we looked at did not contain sufficient detail to demonstrate a safe track record within the practice over the long term."
Positive
"However although information about safety was reported monitored and reviewed records to demonstrate how issues were addressed were not consistently recorded."
Positive
"However the practice was not consistent in recording the analysis and outcome of investigations of all safety incidents."
Positive
"National patient safety alerts were received by one of the GPs."
Positive
"We saw that working practices that could affect patient safety were also discussed for example when the practice found that results from tests they had carried out were not available; they examined the specimen collection transportation and delivery process in place."
Positive
"For example we saw that the practice had taken action to address two recent safety alerts."
Positive
"The practice manager told us that visual health and safety assessments were carried out however these were not documented to demonstrate whether any specific risks related to the practice had been identified to demonstrate action taken or put in place."
Positive
"For example visual health and safety assessments carried out were not documented to demonstrate whether any specific risks related to the practice had been identified to demonstrate action taken or put in place."
Latest Snippet(s)
Positive
"• Staff took steps including working with other agencies to protect patients from abuse neglect harassment discrimination and breaches of their dignity and respect."
2017-10-05 Snippet(s)
Positive
"• Staff interviewed knew how to recognise signs of abuse in children young people and adults whose circumstances may make them vulnerable."
Positive
"• Staff were able to recognise the signs of abuse in older patients and knew how to escalate any concerns."
2015-08-20 Snippet(s)
Positive
"Staff knew how to recognise signs of abuse in older people vulnerable adults and children."
2017-10-05 Snippet(s)
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."
2015-08-20 Snippet(s)
Positive
"Patients were encouraged to sign up to the electronic Summary Care Record."
Neutral
"The practice nurse described to us how they sign posted patients to smoking cessation courses."
Latest Snippet(s)
Positive
"Kindness respect and compassion Staff treated patients with kindness respect and compassion."
Positive
"• Staff involved and treated patients with compassion kindness dignity and respect."
Positive
"• Staff were clear on their roles and accountabilities including in respect of safeguarding and infection prevention and control • Practice leaders had established proper policies procedures and activities to ensure safety and assured themselves that they were operating as intended."
Positive
"Privacy and dignity The practice respected patients’ privacy and dignity."
Positive
"• Staff recognised the importance of people’s dignity and respect."
Positive
"• Staff took steps including working with other agencies to protect patients from abuse neglect harassment discrimination and breaches of their dignity and respect."
2017-10-05 Snippet(s)
Positive
"Kindness dignity respect and compassion During our inspection we observed that members of staff were courteous and very helpful to patients and treated them with dignity and respect."
Positive
"Patients said they felt the practice offered an excellent service and staff were helpful caring and treated them with dignity and respect."
Positive
"They told us staff were respectful caring kind and compassionate and treated them with dignity and respect."
Positive
"• Results from the national GP patient survey showed patients were treated with compassion dignity and respect and were involved in their care and decisions about their treatment."
Positive
"• Survey information we reviewed showed that patients said they were treated with compassion dignity and respect and they were involved in decisions about their care and treatment."
Positive
"Results from the national GP patient survey showed patients felt they were treated with compassion dignity and respect."
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
"The practice manager and GP felt that it was likely that the training log was not up to date and or that staff had not provided their certificates in respect of refresher training attended."
Positive
"• Curtains were provided in consulting rooms to maintain patients’ privacy and dignity during examinations investigations and treatments."
Positive
"For example following a complaint in respect of a prescription issued to a patient the matter was highlighted and discussed at the GPs educational supervision."
2015-08-20 Snippet(s)
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 that they were treated with respect extremely satisfied with their care and treated with compassion."
Positive
"Patientcarer support to cope emotionally with care and treatment The survey information we reviewed showed patients were positive about the emotional support provided by the practice and rated it well in this area."
Positive
"Patients said the practice was welcoming staff were caring polite and understanding and that staff treated them with dignity and respect."
Positive
"We saw that staff treated patients with kindness and respect and were aware of the importance of maintaining confidentiality."
Positive
"They said staff treated them with dignity and respect and were friendly and approachable."
Positive
"Curtains were provided in consulting rooms and treatment rooms so that patients’ privacy and dignity was maintained during examinations investigations and treatments."
Positive
"Staff told us that if they had any concerns or observed any instances of discriminatory behaviour or where patients’ privacy and dignity was not being respected they would raise these with the practice manager."
Latest Snippet(s)
Positive
"• The practice actively promoted equality and diversity."
Neutral
"Staff had received equality and diversity training."
2015-08-20 Snippet(s)
Positive
"Other policies available included equality whistleblowing harassment and bullying at work."
Positive
"Tackling inequity and promoting equality The practice provided equality and diversity training for all staff and we saw evidence of this."
Neutral
"We saw that staff had received training in equality and diversity and that there was a policy for them to refer to."
Neutral
"Staff we spoke with confirmed they had completed equality and diversity training."
Latest Snippet(s)
Positive
"We found that the complaint response letter was not explicit in informing the complainant of the next steps they may choose to take following a complaint investigation and did not stipulate that the practice complaint leaflet was enclosed."
Positive
"The practice complaints leaflet provided patients with information on how to make a complaint and any next steps they may choose to take following a complaint investigation."
Positive
"• Implement changes to the practice complaint response document."
Positive
"• Information about how to make a complaint or raise concerns was available."
Positive
"• The complaint policy and procedures were in line with recognised guidance."
2017-10-05 Snippet(s)
Positive
"For example following a complaint in respect of a prescription issued to a patient the matter was highlighted and discussed at the GPs educational supervision."
Latest Snippet(s)
Positive
"• Structures processes and systems to support good governance and management were clearly set out understood and effective."
Positive
"Governance arrangements There were clear responsibilities roles and systems of accountability to support good governance and management."
Positive
"The governance and management of partnerships joint working arrangements and shared services promoted interactive and coordinated personcentred care."
2017-10-05 Snippet(s)
Positive
"For example; information governance fire safety and infection prevention and control IPC."
Positive
"• We found a lack of systems and processes to enable clear governance in some areas of the practice."
Neutral
"On reviewing staff training files gaps were noted in Infection Prevention and Control IPC refresher training and information governance training all of which were being addressed by the practice manager."
2015-08-20 Snippet(s)
Neutral
"The practice had a number of policies and procedures to govern activity and held regular governance meetings."
Neutral
"The practice held monthly governance meetings to which all staff were invited."
Latest Snippet(s)
Positive
"• Quality and sustainability were discussed in relevant meetings where all staff had sufficient access to information."
Latest Snippet(s)
Positive
"Monitoring care and treatment The practice had a comprehensive programme of quality improvement activity and routinely reviewed the effectiveness and appropriateness of the care provided."
Positive
"• The practice was actively involved in quality improvement activity."
2017-10-05 Snippet(s)
Positive
"There was evidence of quality improvement including clinical audit: • There had been twoclinical audits commenced in the last two years and were due to be repeated."
Latest Snippet(s)
Positive
"• Clinical audit had a positive impact on quality of care and outcomes for patients."
Positive
"This report describes our judgement of the quality of care at this service."
2017-10-05 Snippet(s)
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."
2015-08-20 Snippet(s)
Positive
"This report describes our judgement of the quality of care at this service."
2017-10-05 Snippet(s)
Positive
"• The practice had a variety of other risk assessments 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."
2015-08-20 Snippet(s)
Positive
"Cleanliness and infection control We observed the premises to be visibly clean and tidy."
Positive
"The infection control policy supported staff to plan and implement measures to control infection."
Positive
"We reviewed staff training records and saw that clinical and nonclinical staff were up to date with attending training courses such as basic life support infection control and prevention and safeguarding."
Neutral
"The practice had a lead for infection control who had completed audits related to infection prevention and control."
Neutral
"The lead for infection control had undertaken further training to enable them to provide advice on the practice infection control policy and carry out staff training."
Neutral
"Training records for staff showed that both clinical and nonclinical staff had received infection control training."
Neutral
"We saw evidence that the lead had carried out regular infection control audits and that any improvements identified for action were completed on time."
Neutral
"Staff described how they would use these to comply with the practice’s infection control policy."
Neutral
"For example there was a lead nurse for infection control who ensured that audits completed involved all members of staff."
2017-10-05 Snippet(s)
Neutral
"Staff held regular meeting with the health visitor to discuss child safeguarding."