Waterbeach 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

This means we looked for evidence that there was a culture of openness in which there was a willingness to identify and learn from safety events. We looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment with the previous provider, we rated this key question requires improvement. At this assessment we have rated this key question good.

The practice fostered an open and supportive learning culture in which people could confidently raise concerns. Incidents were investigated thoroughly by managers, which enabled learning and improvement. People were protected and kept safe. Staff understood clinical risks however we found there were some areas of the environment that required increased oversight. The environment, facilities and equipment met people's needs, were clean and well maintained. There were enough staff with the right skills, qualifications and experience. Medicines were managed effectively, and people were actively involved in decisions about changes to their treatment.

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.

There was a proactive and positive culture of safety, based on openness and honesty at the practice. Leaders listened and responded promptly to concerns about safety and investigated and reported safety events. There were processes in place for staff to report incidents, near misses and significant events. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. During staff meetings, everyone attending discussed and learnt from complaints and significant events. Staff told us they felt there was an open culture, and that safety was a top priority.

Staff understood how to identify, and report concerns and were informed of learning as a result. Lessons learnt were continually identified and embedded to ensure good practice. Staff gave a large range of examples of improvements made following incidents and complaints that improved care for others.

People we received feedback from felt supported to raise concerns and felt staff treated them with compassion and understanding. Representatives from the Patient Participation Group (PPG) and some of the local care homes felt that all staff took concerns seriously and proactively made improvements to the service.

Our searches of the practice clinical records system showed that there was an effective process for recording and acting on safety alerts received into the practice, such as those from the Medicines and Healthcare Products Regulatory Agency (MHRA). Clinical guidance from these safety alerts, was embedded into routine practice.
 

Practice staff worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. Staff 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. Referrals and test results were also managed in a timely way. People we spoke with gave positive feedback in relation to referrals being made appropriately and being supported during waiting times to be seen by other services.

The practice worked closely with multiple local care homes. There was a strong focus within the practice to develop positive relationships with both residents and care home staff, to support the shared goal of avoiding unnecessary hospital admissions. Staff told us that they felt this was particularly important for residents with dementia, for whom hospital admission can often be distressing. The practice carried out audits to assess how its collaborative work with local care homes influenced patient outcomes.

Staff told us they had the information they needed to provide safe care and treatment. Staff responsible for making referrals to other services understood the systems and processes that supported timely patient access to further care. Effective tracking systems were in place, including for electronic referrals and urgent referrals for people with suspected cancer.

Practice staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. The service shared concerns quickly and appropriately.

There were dedicated GP leads for safeguarding adults and children. All the staff we spoke with or received feedback from knew who the leads were and what steps they should take if they had any concerns. Many were able to provide examples of when concerns had been identified and addressed.

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. Safeguarding discussions took place during multidisciplinary meetings. There were arrangements in place to follow up vulnerable people who had not attended their appointments.

Practice staff supported people to understand and manage risks while recognising their individual strengths, preferences and goals. Care was delivered compassionately and aimed to empower people to pursue the activities that were important to them. People were advised on risks related to their condition and actions to take if their condition deteriorated.

Emergency equipment was available and maintained. The emergency equipment and medicine were checked regularly and there was clear documentation of the checks made. Staff could recognise a deteriorating patient and knew of action to take. Staff had completed basic life support and anaphylaxis training relevant to their role. There were risk assessments in place in relation to emergency equipment and medicines.

The service did not consistently identify and manage potential environmental risks. During the assessment, we found areas of the premises where visibility was limited, which reduced staff oversight and potentially the ability to promptly mitigate risks. For example, at Waterbeach Surgery, a health pod was situated in a location that was not visible to staff and did not have an emergency call system in place should a patient or staff member require immediate assistance. At the Cottenham site, there were also areas with restricted visibility, which could increase the risk of a delayed response to a medical emergency. In addition, a window without restrictors presented a potential risk. The practice took immediate action to address this by installing a safety closure on the window. Following our feedback, leaders reviewed these concerns and completed a risk assessment and action plan. However, as the measures identified had only recently been implemented further time was required to determine their effectiveness.

There were contracts in place to ensure the premises were maintained. Health and safety risk assessments and audits had been undertaken and actions identified had been addressed. There was a business continuity plan in place which was monitored and reviewed. During the site visit, we observed fire exits were clear and fire safety equipment easily available and had been checked by an external company.

The practice made sure there were always enough qualified, skilled and experienced staff, who received thorough support, supervision and development opportunities. They worked together to provide safe care that met people’s individual needs. Feedback from people was positive in relation to the knowledge, skill, care and treatment provided by clinical staff. People also provided positive feedback about feeling supported by reception and administration staff.

Training was up to date and learning needs for staff development were managed appropriately. Staff were working within their agreed areas of competence. However, safe recruitment practices were not always followed in line with the practice’s recruitment policy.

Recruitment checks help protect people and systems by making sure people are suitable for the roles they are employed to do. Only 1 out of the 3 staff files we reviewed had all the appropriate checks in place. The practice was in the process of transferring staff recruitment records to a new electronic system. During our assessment, it was not always clear whether documents that could not be located were absent from the original records or had not transferred correctly to the new system.

At the time of our assessment, staff were unable to confirm whether an enhanced Disclosure and Barring Service (DBS) check had been requested for a member of clinical staff. Following the site visit, the practice reviewed the records and identified that this had been incorrectly recorded. Leaders took immediate action to address this by requesting a new enhanced DBS check and planned to undertake an audit of all transferred staff files.

We also found no references for another member of staff. Although we saw that references had been requested, they had not been received, and there was no risk assessment in place to mitigate any risks associated with this. Following our assessment, practice leaders completed a risk assessment and requested updated references. Overall, improvements were required to strengthen the oversight and management of staff recruitment records.

The practice effectively assessed and managed infection prevention and control (IPC) risks. Systems were in place to identify and contain the spread of infection, and concerns were escalated to appropriate agencies in a timely manner where required.

The practice had identified IPC leads, and all staff had completed relevant training. Staff we spoke with were aware of who the IPC leads were and were able to describe the procedures for handling clinical specimens and managing bodily fluid spillages safely.

Cleaning schedules were established and consistently followed. The practice carried out risk assessments and audits and took appropriate action to address identified risks. Policies and guidance were available to staff, including as part of the induction process, and were tailored to their roles.

During our site visit, we found the premises to be clean and well maintained. Records demonstrated that cleaning checks were completed regularly, and effective arrangements were in place to communicate with the cleaning contractor and address any concerns. Health promotion materials displayed throughout the practice were laminated or wipeable, in line with the practice's IPC policy.

The practice managed medicines safely and in line with people's needs and preferences. Individuals were involved in decisions about their treatment, including any changes, and were supported to understand how to use and manage their medicines safely. They were also aware of who to contact if their condition did not improve or if they experienced any unexpected symptoms.

Staff received regular medicines management training and competency assessments and were confident in the safe storage, administration, and recording of medicines. Medicines, including vaccines requiring refrigeration, were stored securely and monitored appropriately, with fridge temperatures checked daily. Staff understood the actions required if temperatures fell outside safe limits.

Staff carried out regular checks of stock levels and medicine expiry dates. Medical gases, including oxygen, were stored safely, and prescription stationery was kept securely and managed appropriately. There were no concerns related to the quality of medicines reviews.

Patient Group Directions (PGDs) provide a legal framework that allows some registered health professionals to supply and/or administer specified medicines to a pre-defined group of people. We found that some locum staff administering medicines did not always have the appropriate authorisation to do so. Practice leaders immediately took action to ensure all staff had the required authorisation.

The practice had systems to manage and respond to safety alerts and medicine recalls. There was evidence that safety alerts had mostly been actioned, and people received the correct information about any risks associated with their medicines. Topiramate is a medicine used primarily to prevent migraine headaches and treat epilepsy in adults and children. This medicine is contraindicated in pregnancy unless the conditions of a Pregnancy Prevention Programme are fulfilled. However, our searches identified that not all of the people prescribed this medicine had been informed of this. Following our searches the practice sent evidence that they had informed their patients on this medicine who are of childbearing age of the potential risks.

Our remote clinical searches showed that people received the recommended monitoring when prescribed medicines by the practice. For example, we carried out a search of the practices system and found no issues relating to Disease Modifying Antirheumatic Drugs (DMARDs) or monitoring of people who were prescribed ACE inhibitors.