Ottershaw 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 69 (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.

Managers encouraged staff to raise concerns when things went wrong. There was an effective system in place to record and investigate significant events in line with practice policy. Staff told us there was an open culture, safety was a top priority and incidents were reviewed without blame. During staff meetings, the whole team discussed and learned from clinical issues.

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 processes in place to ensure test results and referrals were managed in a timely way. Referrals to specialist services, including urgent referrals for suspected cancers, included the correct information, and were processed without delay. To ensure all patients were appropriately followed up, staff regularly reviewed a log of these referrals and safety netting procedures were in place.

The practice worked with patients 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. Concerns were shared 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. There were clinical and administrative staff with designated lead roles and responsibilities for safeguarding.

The practice worked with patients to understand and manage risks by thinking holistically. They provided care to meet patient’s needs that was safe, supportive, and enabled patients to do the things that mattered to them. However, emergency medicines were not readily accessible, and risk assessments had not been completed for emergency medicines not stocked.

Staff could recognise a deteriorating patient and knew of action to take, and reception staff used flow-charts to support decisions about patients presenting with concerning symptoms. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

However, during our visit to the practice, we raised concerns about the provision of emergency medicines and equipment. We observed emergency medicines and equipment were not easily accessible as the emergency trolley was stored directly next to an examination couch within a clinical room. Although managers told us the trolley was normally stored outside the privacy curtain, we observed it inside the privacy curtain on the day of the assessment.

We found emergency medicines and equipment were stored in a way that may have made accessing and transporting them difficult, when needed urgently. We identified and raised concerns about the associated risk to people using the service. Items were stacked, unsecured on the trolley, making them difficult to access and posing a risk of falling if the trolley was moved or knocked by a person using the couch.

We also found risk assessments were not in place for items not included in the emergency supplies, as suggested by best practice guidance for primary care

Since our visit, the practice has sent us risk assessments for some of the items not included in the emergency supplies. They also told us they have reviewed the storage of emergency equipment and have made changes to ensure it is accessible and able to be transported safely.

The practice did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. There was a business continuity plan in place which was monitored and reviewed.

Contracts were in place to ensure the premises were maintained. Health and safety risk assessments and audits had been undertaken, which allowed some risks to be identified and addressed.

During our site visit, we identified concerns in relation to the provision of an accessible toilet. We found that the hand soap dispenser was positioned in a way that could limit access for people who use a wheelchair. We also found the practice stored a wheelchair inside the accessible toilet. This reduced the available manoeuvring space and may have made it difficult for people to safely use the facility. The storage of the wheelchair within this area also increased the risk of injury in the event of a fall and may have restricted access to the emergency pull cord. Its proximity to the toilet may also have posed an infection risk.

Since our assessment the practice has provided photographs demonstrating that the soap dispenser has been repositioned appropriately. They told us that arrangements had also been made for the wheelchair to be relocated, to address the identified risks.

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 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.

During our site visit we found recruitment records reflected safe practice guidelines and followed the practice recruitment policy.

The practice did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

The practice had a designated infection, prevention and control lead and all staff had had relevant training. Cleaning schedules were in place and demonstrated clinical room cleaning happening daily.

During our site visit we observed that inappropriate waste was being placed into clinical waste bins and a hands-free clinical bin did not function correctly, meaning that it could not be used safely by staff.

We found that equipment needed to manage spills of bodily fluids was not always in place. We observed a stain on the carpet in the waiting room which had not been effectively cleaned, which may have posed a risk of infection to people using the service. Managers told us the incident had occurred recently and arrangements had been made to deep clean the carpet once the surgery closed following our site visit.

Within the accessible toilet there were baby changing facilities. Processes for cleaning this area were not effectively embedded to assure leaders they were safe.

We also found some gaps in a sample of staff immunisation records. Risk assessments were not in place to mitigate the risk this may pose to staff and patients, and this was not in line with the practice policy.

Following our assessment, the practice told us they have arranged for further staff training around waste management. They also told us they have strengthened processes around infection control and have ensured provision of necessary equipment for managing spills.

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.

Medicines were stored securely and at appropriate temperatures and staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines. The practice had systems in place to manage prescription stationery appropriately and securely.

As part of our assessment, a series of patient clinical record searches were undertaken by a CQC GP specialist advisor. This included a review of the management of patients on medicines that required monitoring. We found patients had received monitoring in line with guidance.

Staff took steps to ensure they prescribed medicines appropriately to optimise outcomes, and prescribing was audited to drive improvements in care and treatment. An audit of antibiotic prescribing had been carried out and the learning from this, had enabled the practice to reduce non-specific antibiotic use in line with national guidance.

The provider had effective systems to manage and respond to safety alerts and medicine recalls. Medicines safety alerts from the Medicines and Healthcare products Regulatory Agency (MHRA) were monitored and distributed to staff for awareness and actioning.

We sampled Patient Group Directions (PGDs), that are used for staff that are not qualified prescribers to administer medications to patients. We found that all PGDs within our sample failed to contain the practice name in the space provided, which is required to correctly authorise their use. Leaders were made aware of this after our site visit and have since told us that this omission has been rectified.