The Blundellsands 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 service had a positive learning culture where staff felt able to speak up and raise concerns. Safety was a clear priority, and the provider took all concerns and incidents seriously. These were discussed openly, properly investigated, and action was taken to help prevent them happening again.

Staff knew how to spot issues and report them, and managers looked into incidents when they happened. People were kept safe and supported appropriately.

There were appropriate systems in place to check on people’s health and review medicines that needed regular monitoring. Medicines were mostly handled well, with a few exceptions which were highlighted to the provider during the assessment. All concerns we identified were dealt with immediately.

There was a clear process for managing safety alerts, and we saw that this worked effectively in practice. There were also procedures to help protect people at risk of abuse, and staff had the right checks and training to make sure they were suitable for their roles.

Staff spoke positively about the leadership and the general safety culture of the service. The premises were safe and well maintained, with proper health and safety processes in place.

However, we did find some areas that needed attention around risk management and staff records. The provider shared an action plan and has completed all required actions.

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 demonstrated and provided evidence of a positive culture of safety, based on openness and honesty. Processes were in place for staff to report incidents, near misses and safety events. The provider listened to concerns about safety and investigated and reported safety events. Staff felt there was an open culture, and that safety was a priority.

Although not always documented consistently, incidents and complaints were investigated, and regular meetings were held where the learning from these was shared and discussed. The provider reviewed significant incidents and complaints to identify underlying themes and trends. Verbal complaints were also documented and reported appropriately. However, actions and outcomes were not consistently documented which made it difficult to identify themes and trends for review.

We discussed opportunities to improve how learning from complaints and incidents was captured and embedded across the service. The provider responded promptly and implemented changes immediately.

The provider worked with people who used the service and healthcare partners to establish and maintain safe systems of care. The provider had systems and processes in place to share information with staff and other agencies to enable them to deliver safe care and treatment. The service worked with other providers to deliver shared care when patients moved between services. Feedback from people who used the service indicated they felt involved in decisions about treatment pathways and they reported prompt follow up care.

Members of the staff team were aware of local services and support networks that they could refer patients to in order to support them with their needs and to prevent ill health. Reception staff had been trained in care navigation to direct patients to the most appropriate service or services to meet their presenting needs. Regular multi-disciplinary meetings were held where the needs of patients with more complex conditions or those approaching the end of life could be discussed.

Clinicians followed care and treatment pathways for treating and referring people to other services. Referrals to secondary or specialist care were made promptly, and patients referred under the two-week wait rule for suspected cancer were followed up appropriately.

Correspondence from secondary care such as discharge letters and summaries were processed quickly and effectively.

People could request a chaperone for intimate examinations if they wished and there was information to alert them to this in the waiting room and in clinical rooms.

The service worked to safeguard people from the risk of abuse. This included working with partner agencies. The provider had systems and processes in place to respond when it was suspected that people may be subject to abuse or neglect. We discussed safeguard training and the provider took steps to ensure that a staff had been provided with safeguarding training at a level that was appropriate to their roles and responsibilities. Staff had a clear understanding of safeguarding and knew who the designated safeguarding lead was. They knew the action to take if they had concerns about a patient’s safety and they told us they would feel confident to report concerns. Alerts were added to the patient record system when a patient was subject to a safeguarding concern so that all relevant members of the staff team could readily identify this. People were well known to the practice. Feedback from people who used the service did not include any concerns with regards to safeguarding. Staff recruitment procedures were in place to ensure staff were suitable to work in the service but this was not always documented consistently. The provider took steps immediately to rectify this.

The service worked with people to understand and manage risks by thinking holistically. Initial assessments included recording people’s physical, psychological and personal circumstances and people had care plans in place. Information was also available online to help people understand their long term conditions and how to manage them. The care and treatment provided was safe, supportive and encouraged people to remain healthy and do the things that mattered to them. People were advised on risks related to their condition and actions to take if their condition deteriorated.

The service was located in a purpose built building that provided the required facilities such as safe access for people with physical disabilities. The premises were clean and contained the appropriate facilities to support infection prevention and control. The provider detected and controlled potential risks in the environment. Leaders made sure equipment, facilities and technology supported the delivery of safe care. Regular checks were carried out on the premises, facilities and equipment provided. Contracts were in place to ensure the premises were clean and well maintained. Health and safety related assessments and procedures to manage health and safety were in place. This included fire safety. Staff had been provided with training in health and safety related topics such as fire safety, infection control and manual handling. There was a business continuity plan in place to provide guidance for dealing with a major disruption to the service, for example an IT failure.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and opportunities to develop. Staff told us they had regular protected learning time (PLT) meetings where relevant practice business such as safeguarding, complaints and actions for improvement were discussed. Staff had completed training appropriate and relevant to their role. The clinical team had recently experienced periods of staff absence due to unforeseen circumstances, which had affected the provision of appointments. However, the situation had since improved, with staff returning to work and new team members being recruited. Staff in all roles told us there was enough of them to provide safe, high quality care and they worked effectively as a team. There were appropriate arrangements in place for covering staff sickness, absence and vacancies and the use of temporary staff was minimal. We looked at the recruitment records for a sample of staff. These showed recruitment practices were mostly carried out in line with requirements. We discussed the implementation of a standard recruitment list to ensure consistency in each personnel file with leaders.

The facilities and premises were appropriate to support cleaning and reduce the spread of infection. Personal protective equipment was in good supply and located appropriately around the premises. The provider assessed and managed the risk of infection. There were clear roles and responsibilities around infection prevention and control with a dedicated lead person and staff had undergone training appropriate to their role.

Cleaning schedules were in place and infection prevention control and cleaning audits were carried out on a regular basis. Cleaning equipment was stored securely and in line with best practice. The arrangements for managing waste, sharps and clinical specimens kept people safe.Staff vaccination was mostly maintained in line with current UK Health and Security Agency (UKHSA) guidance. At the time of the assessment updates were required for some non-clinical staff. There was a system for the service to report infection-related concerns to the relevant agencies (e.g. notifiable diseases).

The provider made sure that medicines and treatments were safe and met people’s needs. We reviewed clinical records for patients who had been prescribed medicines which required routine monitoring. Our review showed that the provider managed medicines safely and their approach to medicines reflected current and relevant best practice and professional guidance.

Our review of records showed that people taking medicines with specific risks that required monitoring were appropriately monitored before their medicines were prescribed. We identified that not all patients over the age of 75 on antiplatelets were documented as being offered a medicine to avoid potential gastric side effects from their prescribed medicines. We pointed this out to the provider and appropriate action was taken for each patient immediately where this was required. Regular medicines reviews were carried out for people who used the service to ensure their medicines were safe and appropriate to their needs.

Staff had access to emergency medicines and equipment including oxygen and a defibrillator. Emergency medicines were regularly checked for stock availability and to ensure they were in date. Vaccines were stored appropriately, and regular checks were carried out to ensure safe storage and stock.

The provider had effective systems to manage and respond to safety alerts and medicine recalls. Appropriate action had been taken in response to the medicines alerts we looked at. The provider had appropriate authorisations in place for Patient Group Directions (PGDs) (written instructions to supply or administer medicines to patients in planned circumstances for example, vaccinations. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.