Colney Hatch Lane Surgery

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• 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.

The scores for the quality statements not assessed as part of this key question are based on the previous inspection rating for safe for the previous provider of services at this location.

This is the first inspection for this service since its registration with CQC. This key question has been rated as Good.

This service scored 66 (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.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. We reviewed meeting minutes for the period of six months prior to our assessment and found that whilst concerns relating to safety were discussed, we did not see evidence of how the provider of the service assured themselves that any learning was thoroughly embedded and applied by staff within the service. Meeting minutes showed managers encouraged staff to raise concerns when things went wrong, however we saw limited evidence of how management dealt with any concerns raised by members of staff.

Clinical staff meetings were held regularly, and we saw evidence the clinical team and the service manager discussed and learnt from clinical issues. Staff felt there was an open culture in relation to safety, and that safety was a priority. The provider had processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. The provider of services gave examples of learning from incidents and complaints which resulted in changes that improved care for others. However, there was no written record of embedding any learning among all surgery staff in the staff meeting minutes we viewed.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for this key question for the previous provider for this location. The previous provider of services at this location is a partner at this 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 policies were in place, but the location of these policies were not known to all members of staff, and not all staff were appropriately trained in safeguarding procedures. The service maintained a list of vulnerable people and acted on concerns working collaboratively with other organisations.

There were systems in place to follow up people who failed to attend important health care appointments or were frequent attenders to the emergency department.

People were offered chaperones for intimate examinations or procedures. Staff had received training on chaperoning and had a clear understanding of their role.

The service worked with people to understand and manage risks using a holistic approach. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The service had engaged with people to obtain their views on access to health care professionals. This was achieved by the service asking patients to review their experience of care through completing the Friends and Family Test after their most recent visit to the service.

The National GP Patient Survey data and feedback received from people (at the time of this assessment) reflected that 59% of people responded moderately positively to the overall experience of contact with their GP practice with the national average being 67%.

There were systems and processes in place to identify and manage emerging risks of people and regular liaison with other health care professionals to highlight the risk, for example, with the community nursing team, palliative care team and referrals to secondary care.

On the day of our site visit, we identified that not all staff had been recently trained in basic life support (BLS). We spoke with the service regarding this, and they informed us that action had been taken to procure face-to-face BLS training for staff. The provider told us that staff could recognise a deteriorating person and knew the action to take and staff we spoke with verified this. We noted that of the five training records we viewed, only two members of staff had undertaken Sepsis training in the 12 months prior to our visit. We spoke with the provider about this who informed us that staff would be reminded to complete all required annual training within specified timescales. The service advised patients on risks related to their condition and the actions to take if their condition deteriorated.

The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities or technology supported the delivery of safe care.

The service was responsible for all risk assessments, cleaning arrangements and maintenance of the buildings. The service had clear security arrangements, but we were not assured that these arrangements kept people safe. On our site visit, we identified that there were areas where patients were able to access, that were not adequately restricted or monitored by the service. These areas included areas with patient information that were not monitored by surgery staff. We spoke with the service about this on the day of the site visit and they told us that was very rare for patients to be in the identified areas, but they would seek to put additional measures in place.

There was limited evidence that the service had effective systems to monitor and comply with mandatory risk assessments, including fire safety and legionella testing to ensure that people and staff remained safe.

There was no evidence that fire alarms were routinely tested, and the service did not have evidence that fire drills were undertaken. In addition, we asked the service for a copy of their fire safety and health and safety policies, but we did not receive these.

We did not identify clear signage at the service where the meeting point for patients and staff was in the event of a fire. Members of staff told us that they were only told who the Fire Marshal(s) were a couple of days before our site visit. Of the five training records we reviewed, we identified three Fire Marshals, all of whom had in date training. We noted fire safety training on the remaining staff training records. The service provided us with an annual maintenance inspection certificate undertaken by an independent fire engineer in November 2023.

Electrical equipment had been calibrated and tested. Safety alerts relating to equipment were shared with the relevant staff and acted on.

We observed that the service was accessible for all people and included space for wheelchairs and prams. Hallways and corridors were clean and tidy and free from clutter. Staff offices were locked if there were no staff members in the room, otherwise they remained open and accessible to all. All rooms at the service were lockable using a key. We queried this with the service provider in relation to staff safety and accessing/exiting rooms, who told us they would take on board our observations

The service made sure there were enough qualified, skilled and experienced staff, but there was no consistency in who received support and supervision. Similarly, there was no consistency in staff undertaking required training or when it was undertaken. Staff 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. Not all training records we viewed were up to date. For example, we noted that the named safeguarding GP lead at the service did not have the correct level of training for this additional role. We also identified that not all learning needs and development of staff was managed appropriately.

The service told us that they used an online training platform for staff and that staff were required to complete required training within a specific timeframe. We reviewed a sample of training records (downloaded by the service) and found that the amount of training completed by staff varied, indicating a lack of oversight by management.

Not all recruitment practices were safe for recently employed staff, including lack of evidence within staff files of proof of identity, references, disclosure and barring service (DBS) checks and a record of staff immunisations.

There was limited evidence of annual appraisals for non-clinical staff. The service providers told the assessment team that this was a forthcoming area of improvement for them.

At the time of our assessment, the service employed a locum practice nurse who held clinics one day a week.

There were systems in place to assess and manage the risk of infection. We saw evidence that clinical rooms were checked daily for cleanliness and equipment was cleaned after each use. Disposable curtains were in use in all clinical rooms, and a diary date for when they needed to be changed recorded. Medical couches were all in good state of repair and were visibly clean. Disposable couch rolls were used and replaced immediately if it was used as part of a consultation.

The service used disposable single use equipment at all times and records showed that equipment was appropriately disposed of after use. For example, cervical cytology speculums, and mouth pieces for the management of respiratory conditions, such as spirometry breathing measurements were disposed of in the appropriate clinical waste bins.

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

The service had a designated infection, prevention and control lead and all staff had had relevant training. Cleaning schedules were in place and followed. Infection prevention and control audits were completed, and actions taken to mitigate risks.

The service 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.

The service made sure that medicines and treatments were safe and generally met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

Systems were in place for checking and monitoring emergency equipment and medicines. The service kept recommended emergency medicines and equipment, including oxygen, and defibrillator on site.

Staff used protocols to ensure they prescribed medicines safely, and ensured people received recommended medicine reviews and monitoring. We found some minor inconsistencies in using some clinical protocols at the service, which we discussed with the service during the clinical records review. As a result of this discussion, the service provided us with an update of actions they had taken to rectify the inconsistencies identified.

Established processes were in place to ensure that people prescribed medicines with specific risks received recommended monitoring. The service prescribing of antibiotics to treat infections was comparable to the national average of prescribing of these drugs.

As part of the assessment, we reviewed the service prescribing of direct oral anticoagulants (DOACs), to confirm that the service was prescribing and monitoring these medicines in line with national guidelines. We found that the service was monitoring all but one patient correctly. This elderly patient had not been monitored in line with national guidelines, despite there being several alerts/flags on their clinical record to undertake required monitoring.

Relevant staff received regular training and were competency assessed on medicines optimisation. Staff felt confident managing the storage, administration and recording of medicines. Staff managed prescription stationery appropriately and securely. 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. Waste medicines were disposed of appropriately. Staff stored medical gases, such as oxygen safely.

The provider did not have completely effective systems to manage and respond to patient safety alerts and medicine recalls. Whilst there were systems in place to review and monitor new and recent alerts, this process did not always extend to ongoing long-standing safety alerts. We reviewed the appropriate prescribing of the medicines Citalopram and Escitalopram (prescribed to treat several conditions including low mood and anxiety) to specific patients. During our remote clinical records review, we identified 3 patients who had been prescribed these medicines, who had not been informed by the provider of the potential risk of the medication prescribed interacting with other prescribed medication being taken. We spoke with the service provider about our findings and emphasised the importance of monitoring all active medicines safety alerts to ensure patient care is in line with current guidelines.

Overall, staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring. However, we identified that appropriate monitoring for patients prescribed lithium was not always being undertaken according to national guidelines. We identified two patients who had not had a blood test in line with national guidelines of every three months.