ELM Alliance @ Park Surgery

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that people were protected from abuse and avoidable harm.
This is the first inspection for this service since its registration with CQC. This key question has been rated as Good.
 

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. Managers encouraged staff to raise concerns when things went wrong. During meetings, staff discussed and learnt from clinical issues. Staff felt there was an open culture, and that safety was a top priority. Learning from incidents and complaints resulted in changes that improved care for others.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.
As a GP Enhanced Access Service, there were systems in place for processing information safely between the service and patient’s GP practice. Referrals and test results were managed in a timely way and processes were in place to ensure that any results or outcomes were relayed back to the patient’s main GP service.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately. Safeguarding leaders and policies were in place and known to staff. For example, there was a clear chaperone policy that ensured a trained chaperone would be present where required. Staff were appropriately trained in safeguarding procedures, and we saw records that confirmed this. The service, alongside other providers, was involved in local initiatives aimed at strengthening and improving local safeguarding functions and improving outcomes for vulnerable patients.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.
Emergency equipment was available and maintained. Staff could recognise a deteriorating patient and knew of action to take. For example, basic life support training was mandatory for all staff employed at this service. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.
 

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The service had a lease agreement in place with a third party for the delivery of GP Enhanced Access in the premises. Health and safety risk assessments and audits had been undertaken and risks identified had been addressed. The emergency trolley was mobile, accessible enough for the setting and appropriately stocked. There was a process in place for monitoring the expiry dates and replacement of emergency drugs. Staff received fire safety training as part of mandatory requirements. Key staff also received the additional fire marshal training to ensure there was a fire marshal present at every session. We saw records indicating that regular fire safety checks were completed regularly. There was a business continuity plan in place which was monitored and reviewed.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.
There were a range of clinical and non-clinical roles within the service. Duty rotas were planned in advance and designed to support staff wellbeing ensuring adequate rest periods for staff. There were clear escalation plans to address any unplanned absences. These plans relied on utilising bank or agency staff where necessary. We found training was up to date, learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence. Safe recruitment practices were followed.
 

Infection prevention and control (IPC) policies were in place and were updated regularly. The service had a designated infection, prevention and control lead and all staff had had the relevant training. Cleaning arrangements were in place as part of the lease agreement with a third party. Nevertheless, staff could still access cleaning products and equipment for use to manage, for example, spillages. Cleaning agents were kept in secure storage in accordance with the Control of Substances Hazardous to Health Regulations (COSHH) regulations. We saw evidence of cleaning schedules being adhered to. Regular IPC audits were conducted to assess compliance with, for example, hand hygiene, cleaning protocols and waste management.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened. There was a comprehensive medicine management policy in place. As an enhanced access service, they did not keep any medication on site apart from emergency medication which was stored securely on the emergency trolley. The emergency trolley was sealed with numbered tamper-evident security tags. Staff received regular training and were competency assessed on medicines optimisation, managing the storage, administration and recording of medicines. The service primarily relied on the electronic prescribing functionality within their electrical clinical system to provide prescriptions. However, they also kept paper prescription pads for business continuity purposes. These prescription pads were stored securely, and there were robust procedures in place to ensure accountability and prevent misuse. Staff followed protocols to ensure they prescribed all medicines safely, and ensured people received all recommended medicines reviews and monitoring. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.