Satis House

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 new registration with Care Quality Commission (CQC). This key question has been rated as good.

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 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.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. Representatives from the Patient Participation Group (PPG) felt the provider took concerns seriously and proactively made improvements to the service, such as, the service had facilitated adaptations to the appointment booking system where the telephone lines informed people how long their queue time was when they called the practice.

Managers encouraged staff to raise concerns when things went wrong. During staff meetings, the whole 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. 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. For example, the service demonstrated learning from a significant event relating to the prescribing and titration of medicines. As a result, it strengthened the management and monitoring of medicines prescribed by external healthcare providers.

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.

There were systems in place for processing information relating to new patients. The service worked with other providers to deliver shared care and when patients moved between services.

Referrals and test results were managed in a timely way. For example, we observed as part of our clinical records review the effective use of technology to proactively assess people’s needs and identify when individuals were due follow-up for long term conditions or vaccinations. The system enabled the service to identify those people who required early intervention and supported the timely delivery of care and treatment.

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 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 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 we spoke to informed us of how they recognised 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 overall detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. However, the service did not always effectively identify and mitigate environmental risks. For example, access to emergency equipment was restricted by controlled doors, and during the inspection we observed staff had difficulty gaining access. In addition, the waiting area was not directly visible to staff, which meant staff may not have been able to recognise if a person’s condition deteriorated and they required assistance. We raised the associated risks with service leaders during the inspection, including the potential risk to people who may require emergency care.

Leaders were responsive and took action to mitigate the risks identified. Following the inspection, the service provided evidence that changes had been made to the environment to improve safety.

Contracts were in place to ensure the premises were maintained. 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 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 service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies.

The practice had a designated infection, prevention and control lead and all staff had had relevant training. Risk assessments and audits were completed, and actions taken to mitigate risks.

Cleaning schedules were in place; however, we found that the cleaning schedule did not have up to date documentation for the building. The leaders informed us that they were in contact with the cleaning contractors to address this.

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.

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. Staff managed prescription stationery appropriately and securely.

Staff followed protocols to ensure they prescribed all medicines safely, and ensured people received all recommended medicines reviews and monitoring. For example, we reviewed a sample of five medicine reviews and found these were appropriate, with people monitored in line with their clinical needs.

Medicines were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines, vaccines and medical gasses such as oxygen.

Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. Prescribing data reviewed as part of our assessment confirmed this. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.