The Ridgeway 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 updated registration with 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 practice had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns and investigated and reported safety events. There were clear processes for staff to report incidents, near misses and safety events. Leaders encouraged staff to raise concerns and report incidents which were discussed at regular meetings and daily huddles,if it was urgent. Learning from incidents resulted in changes that improved care for others. People felt supported to raise concerns and felt staff treated them with compassion and understanding.

The practice worked with people and healthcare partners to establish and maintain safe systems of care. There were systems in place to ensure continuity of care, including when patients moved across health and social care pathways. There were protocols in place for managing incoming correspondence into the patient’s medical records. The practice had completed a document handling audit and found all documents were appropriately directed to either the GP or required no further action. Our review of records showed that pathology and blood tests results were managed in a timely manner. Patient referrals to specialist services were documented in the referral systems and patient records. We found these were managed in a timely manner.

The practice worked with patients and healthcare partners to understand what being safe meant to them and the best way to achieve that. They had a designated safeguarding lead, and all staff had completed the relevant training for their role. The practice had appropriate management and oversight of safeguarding. They had registers for vulnerable adults and children and there was evidence this was regularly reviewed and updated. Clinical system alerts were used to identify people who were at risk of harm or abuse including household contacts. There were systems in place to respond to concerns and act on correspondence. For example, they followed up children who failed to attend their appointments and AE attendances. Safeguarding meetings were held on a regular basis to review people at risk which included external professionals such as health visitors.

The practice worked well with patients to understand and manage risks. They provided care to meet people’s needs that was safe and supportive. Staff could recognise a deteriorating or acutely unwell person and knew of action to take.

The practice had mostly detected and controlled potential risks in the care environment. Health and safety risk assessments had been undertaken, and leaders completed a health and safety checklist twice a year. We saw evidence that the actions identified had been completed. Systems were in place for the checks of fire alarms, fire extinguishers and fire evacuation procedures. Portable appliance testing was completed annually to ensure equipment was safe to use. We found there were no emergency pull cords in the patient toilets. The practice acted promptly to provide evidence that this had been rectified.

The practice made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. Safe recruitment practices were followed. We reviewed 5 personnel files and found appropriate checks such as previous employment record, proof of identity and references had been completed. We found most training was up to date and the practice provided evidence to demonstrate training gaps were completed following our visit. Staff told us they felt supported with their personal development and were given opportunity to learn. For example, they supported one of their receptionists through a Health Care Assistant (HCA) course and supported them to become a qualified General Practice Assistant (GPA).

The practice assessed and managed the risk of infection. The practice had a designated infection, prevention and control lead and most staff had completed relevant training. The practice was responsive and provided evidence demonstrating gaps had been rectified. Risk assessments and audits were completed, and actionswere taken to mitigate risks. Cleaning schedules were in place and followed. Clinical rooms had adequate provision of personal protective equipment (PPE) and handwashing facilities.

The practice made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines, vaccines and controlled drugs. We found some gaps in the monitoring of the fridge temperatures. The practice took immediate action and made changes to the fridge monitoring forms to reduce the likelihood of missing monitoring in the future. Staff stored medical gases, such as oxygen safely. There were suitable processes for staff to follow when dispensing medicines. As part of our inspection, 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 most patients had received monitoring in line with guidance. We reviewed 5 patients records who had a medication review in the past 3 months and found no issues with the monitoring of these patients. We found Patient Group Directions (PGDs) (written instructions to supply or administer medicines to patients without a prescription or an instruction from a prescriber) were in good order. However, our review of Patient Specific Directions (PSDs) (instructions to supply or administer a medicine to a list of individually named patients where each patient has been individually assessed by that prescriber) had gaps identified. We raised this with the practice who acted promptly to put these in place and updated their protocol. This included a monthly set of searches to highlight any patient having a prescription without a PSD. There was a programme of regular clinical audits that focused on improving care and treatment.