Ambrose Avenue Group Practice

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 service scored 75 (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 demonstrated a positive culture of safety. We saw they listened to concerns about safety and investigated and reported safety events. Evidence was seen that lessons were learnt and actions taken to embed good practice.

Staff told us they felt supported to raise concerns. Leaders encouraged staff to raise concerns when things went wrong. We reviewed significant event meeting records and found the team discussed, acted on, and learnt from events. The practice had processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints. We saw when things went wrong, staff apologised and gave people support.

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.

We received positive feedback from people relating to the management of test results and timely, appropriate referrals. Care home representatives confirmed people who had recently moved into a care home were able to register easily with the practice.

We saw tests results at the time of our assessment had been acted on and cleared within 48 hours. The practice had a process to ensure cervical cytology results were received and acted on appropriately. The practice worked with other providers to deliver shared care including when people moved between services.

The practice worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. The practice protected peoples’ right to live safely, free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect. The practice shared concerns appropriately. People we spoke with had no specific views or concerns in this area. Staff told us they had received training in safeguarding children and adults, were confident to report any concerns and knew who the safeguarding leads were at the practice. Safeguarding policies were in place and known to staff.

The practice held a list of vulnerable people to enable them to understand and review those at risk regularly. The practice held meetings where safeguarding was discussed. We reviewed the meeting minutes and saw actions to be taken were discussed and documented in people’s records.

Arrangements were in place to follow up vulnerable people who had not attended for a healthcare appointment, this included for example, post-natal, and secondary care appointments for children and vulnerable adults. However, we found the safeguarding review process at the practice did not include recording all household members to support staff understand the concerns affecting all those in a household that could be at risk. Following the assessment, we received assurances the practice processes had changed to reduce this happening in the future.

People told us staff worked with them to understand and manage risks. Staff showed us they had the appropriate information available to provide care that met people’s needs. This ensured people were safe and supported, and staff had documented what mattered.

Care home representatives told us practice clinicians involved people, their carer’s, and family appropriately to ensure care and treatment met individuals’ needs and preferences.

Staff confirmed they had guidance to recognise, assess, and manage people whose health was deteriorating, and to manage medical emergencies. Emergency equipment was available and maintained. Staff we spoke with told us they knew the action to take if people’s health was deteriorating. The practice had an accessible daily duty GP available for advice and support when necessary.

The practice detected and controlled potential risks in the practice environment. They made sure equipment, facilities and technology supported the delivery of safe care.

We saw potential risks were monitored in the practice environment and any actions that were needed had been addressed. The practice equipment, facilities and technology supported the delivery of safe care. People who provided feedback at this assessment told us they felt safe receiving their care and treatment and had no concerns about the practice’s environmental safety.Ongoing checks relating to fire safety, electrical safety and equipment calibration were up-to-date and complete.

During the onsite assessment, we observed fire exits were clear and fire safety equipment was available and had been checked.

There was a business continuity plan in place which was held securely off site, monitored, and reviewed.

There had been a period of instability and high turnover of staff at the practice over the last 18 months prior to them registering with the CQC. At the time of this assessment, we were provided with the evidence to show all the staff training that had been undertaken. Staff told us they were encouraged by leaders within the practice to undertake both mandatory and role specific training and given time and support. Staff told us they worked well together as a team to provide safe care that met people’s individual needs.

Feedback from people and representatives from care homes were positive about the knowledge of clinical staff and the clinical care provided by the practice.

Following the practice leaving their previous organisation and registering with the CQC, they had taken the responsibility for staff personnel files and been working to improve the records held. We did find missing pieces of information within the staff records; however, we received assurance of changes to practice processes to manage staff records for the future. The recruitment processes included assurance that professional registration of clinical staff was checked at recruitment and on an ongoing basis and all new staff received an induction programme that was tailored to their role.

New staff members told us they had received an effective induction programme and felt supported by leaders and colleagues in their teams with supervision and felt they were working within their agreed areas of competence.

We observed appropriate processes and procedures in place at the practice to assess and manage the risk of infection. The practice had an updated policy and a lead nurse, for infection prevention and control (IPC). The IPC lead carried out regular monitoring, audits, IPC staff training, and attended IPC meetings. The IPC lead had support from the Integrated Care Board (ICB) IPC lead, and a GP Partner at the practice for clinical support and advice.

Feedback we received from people at the time of this assessment was positive in respect of the cleanliness of the practice environment.

We saw cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks.

There were records of equipment cleaning and appropriate arrangements to manage clinical waste were in place.

Policies and guidance was available for staff, and they had completed training relevant to their role. Staff told us they had no IPC concerns and about the systems in place for safely dealing with clinical specimens and spillage kits were available.

We received assurance of the legionella checks, and the monthly handwashing audits carried out to ensure staff followed safe practices. (Legionella is a term for a particular bacterium which can contaminate water systems in buildings).

The practice had systems in place to support the safe and effective use of medicines. The practice ensured medicines and treatments were safe, and met people’s needs, capacities, and preferences. They involved people in managing their medicine, this included when changes happened.

Medicines were stored securely, and prescription stationery was tracked using serial numbers and logs. Fridge and ambient room temperatures were monitored daily at both sites. Staff described a clear process for responding to temperature control for medicine, including escalation, quarantine, and the use of a data logger to capture accurate information about any deviations.

Emergency equipment such as defibrillators and oxygen cylinders were available and routinely checked. Expiry dates of emergency medicines were recorded, and at the time of this assessment we found emergency medicine stock to be appropriate at both sites, and in line with best practice.

We received positive feedback from 2 people in relation to medicines management during the onsite assessment. They told us they were regularly called into the practice to have their medicine reviewed. The care home representatives told us the repeat prescription ordering process worked well, people’s medicines were regularly reviewed, and staff answered and dealt with any queries in a timely manner.

Repeat prescribing was supported by effective procedures and staff were clear about the escalation process for urgent reviews. The practice maintained a log of medicine shortages and liaised with local pharmacies to source suitable alternatives. Discharge summaries were reconciled promptly and uploaded to the clinical system, ensuring timely actions when other providers changed medicines.

Patient Group Directions (PGDs) were in place, up to date, and authorised by the clinical lead GP. Nurses were appropriately authorised to administer medicines under PGD’s. Staff also described designated lead roles among nurses, covering areas such as diabetes, respiratory care, infection prevention and control, and palliative care. The practice used computer software to support medicines management and patient communication.

The practice received safety alerts from the Medicines and Healthcare products Regulatory Agency (MHRA). The practice acted on alerts, and we saw evidence that the actions needed for people affected by the alerts had been completed.

A CQC GP Specialist Advisor performed remote searches of the practice patient records. Clinical searches identified 4 people prescribed a medicine subject to a patient safety alert that did not appear to have received the information required for the medicine they were taking. At the site assessment, we were given assurance these people had received information or no longer required the information, and records were documented appropriately. People prescribed Disease Modifying Anti-rheumatic Drugs had all received their appropriate monitoring in the last 6 months however, in the 5 randomly selected records we checked; 2 did not have the condition they were taking the medicine for, and 4 did not show the day of the week the medicine should be taken. At the site assessment we were given assurance that changes had been made to people’s records and that checks in the future would ensure these were not missed from records. The searches for people prescribed medicine for their high blood pressure, of the 5 randomly selected records we checked, 3 were appropriately monitored and 2 had not received medicine for more than 6 months. At the site assessment we were given assurance these people had been contacted and changes made to records. Long-term conditions reviewed by the GP specialist advisor identified that Diabetes, Hypothyroidism, CKD, and Asthma conditions were appropriately monitored, with no concerns.

A range of prescribing indicators were reviewed, for example, antimicrobials, antipsychotics, and antibiotics. The practice indicators showed no statistical variation range for these medicines over the last year against local and national expected statistical data. We were provided evidence of regular reporting undertaken to understand prescribing and this demonstrated the practice’s focus on improving prescribing habits, care, or treatment at the practice.