Aelfgar 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

The practice had a good learning culture and people could raise concerns. Leaders investigated incidents and discussed changes made to reduce the risk of reoccurrence. The documentation reviewed showed a lack of a detailed route cause analysis and risk mitigation, although staff spoken with assured us these were fully discussed in their meetings. People were protected and kept safe. Staff understood and managed risks. The facilities and equipment met the needs of people, were clean and well-maintained. There were a small number of environmental areas the Care Quality Commission (CQC) identified for the practice to add to their repairs and maintenance list and to ensure any risks were mitigated. The practice was a tenant of an older building with no capacity for growth on their ground floor footprint. New build housing developments were planned and taking place which had the potential to impact the practice with a growth in the patient list. We found that 1 emergency medicine used to treat very low blood sugar was said to be stocked was absent. We fed this back to the practice and the medicine was replaced. Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring. Our clinical searches however identified areas to strengthen. There were enough staff with the right skills, qualifications and experience. Leaders made sure staff received training, had regular appraisals and that staff with additional roles and responsibilities were in receipt of clinical supervision and competency reviews.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice 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.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. Leaders encouraged staff to raise concerns when things went wrong. During staff meetings, the team discussed and learnt from clinical issues. Staff felt there was an open culture, and that safety was a top priority. The provider had processes for staff to report incidents, near misses and safety events. The documentation reviewed showed a lack of a detailed route cause analysis and risk mitigation, although staff spoken with assured us these were fully discussed in their meetings. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Learning from incidents and complaints resulted in changes that improved care for others.

The practice 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.

There were systems in place for processing information relating to new patients. The practice worked with other providers to deliver shared care and when patients moved between services. Referrals and test results were managed in a timely way.

The practice 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 practice shared concerns quickly and appropriately.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations.

The practice 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. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

The practice detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. There were a small number of environmental areas the Care Quality Commission identified for the practice to add to their repairs and maintenance list and to ensure any risks were mitigated.

Contracts were in place to ensure the premises were maintained. Health and safety risk assessments and audits had been undertaken and risks identified had been addressed. There was a business continuity plan in place which was monitored and reviewed.

The practice was a tenant of an older building with no capacity for growth on their ground floor footprint. New build housing developments were planned and taking place which had the potential to impact the practice with a growth in the patient list.

The practice 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 practice. 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.

The practice assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The practice had a designated infection, prevention and control lead and all staff had had relevant training. The Care Quality Commission noted a few gaps in the practice infection prevention and control (IPC) policy, which were rectified during the site visit. A Control of Substances Hazardous to Health (COSHH) item was seen in a couple of rooms and were removed to the lockable storeroom during the onsite visit, as they contained chemicals that could be harmful if not handled properly. The practice had conducted an IPC audit, and the subsequent action plan had been completed. The provider held a copy of their completed IPC annual statement. Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks.

The practice 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.

Staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely. People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms. Staff received regular training, were competency assessed on medicines optimisation, and felt confident managing the storage, administration and recording of medicines.

The practice maintained a prescription protocol which was updated and forwarded to the Care Quality Commission post the onsite inspection feedback. Monthly clinical supervision sessions were held and staff had access to a duty doctor each working day.

The provider had effective systems to manage and respond to safety alerts and medicine recalls with the Primary Care Network pharmacy technician being responsible for receiving, disseminating and actioning patient safety alerts. Independent prescribers were subject to clinical supervision and audit of their prescribing.

Staff managed prescription stationery appropriately and securely. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments. Medicines were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines. When we reviewed the emergency medicines,we saw that one medicine used along with emergency medical treatment to treat very low blood sugar was absent. The practice list of stocked emergency medicines suggested this was a necessary emergency medicine to stock and therefore did not have a risk assessment. This was discussed with the practice leaders who assured us this was an error, and the medicine was replaced.

Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring. Our clinical searches however identified areas to strengthen. This included blood pressure monitoring for a particular medicine used to ease an overactive bladder and for patients who potentially required co-prescribed medicines to reduce the risk of gastrointestinal complications. The provider took measures such as recalling these patients for a medicines monitoring review to mitigate any potential risks following our assessment.

Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.