Canberra Old Oak 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. At our last inspection in November 2022, we rated this key question as good. At this inspection, the rating remains the same.

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.

Managers encouraged staff to raise concerns when things went wrong. During staff meetings, the team discussed and learnt from clinical issues. Staff felt there was an open culture, and that safety was a high priority.

The service ran multiple practices across England and London and had a centralised incident reporting system (known as RADAR) so that learning could be reviewed and shared across all its services as relevant. Staff were trained on how 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.

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 now being managed in a timely way, with a system to sort and allocate tests across the clinical team each morning, and checks completed at the end of the day to ensure results had been actioned.

The GPs demonstrated that they advocated for people when issues were not immediately resolved, for example, resubmitting rejected referrals with additional information if they believed the referral remained clinically appropriate.

The service supported people if they preferred to use independent healthcare providers to manage aspects of their health. If the person’s GP believed a course of independent treatment might pose a risk, they discussed it with the person and sought specialist advice if necessary.

Very urgent results were prioritised for immediate action, for example, if the person was assessed as needing to attend AE. Urgent referrals were tracked to ensure people received and attended these appointments. The service had built up a backlog of clinical correspondence and test results at the time of the inspection but this had been risk-assessed and a plan had been implemented to clear the backlog of ‘routine’ documentation.

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

The service was located in modern purpose-built premises. There was a ground floor reception and security in place to control entry to the building which was shared by several different health services and teams. Contracts were in place to ensure the premises were maintained. Health and safety risk assessments and audits had been undertaken and risks identified had been addressed. 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.

There were systems in place to ensure there was effective oversight of advanced practitioners, physician assistants and non-medical prescribers. These included daily debriefs; regular teaching sessions; observation of consultations and records audits.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

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

The service generally made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. However, our inspection showed that some patients were overdue medicines reviews and the service had not fully implemented prescribing guidance in relation to salbutamol inhalers.

Prescribing staff followed protocols to ensure they prescribed medicines safely and to optimise care outcomes including antibiotics. Prescribing data reviewed as part of our assessment confirmed this. For example, the number of antimicrobials issued by the provider was lower than local and national averages.

Our clinical searches showed that the service was generally managing prescribing in line with guidelines although there were areas for improvement. For example, the searches showed that some patients were overdue medicines reviews. The service had recently recruited an additional clinical pharmacist to increase its capacity to complete reviews in a timely way. Completed structured medicines reviews were clear, included all necessary information and showed that people were involved in reviews of their medicines.

We also found that some asthma patients still had regular repeat prescriptions for salbutamol inhalers which is no longer recommended practice. (Frequent use of salbutamol inhalers can mask poor asthma control and consequently leave people at greater risk of a severe attack). Following the inspection, the service confirmed that it would review these cases and its prescribing policy and protocol so that salbutamol inhalers would only be prescribed as necessary.

Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring. The service had effective systems to manage and respond to safety alerts and medicine recalls. There was a programme of regular clinical audits of prescribing and teaching sessions that focused on improving care and treatment.

Staff were appropriately qualified; received regular training and felt confident managing the storage, administration and recording of medicines. Non-medical prescribers were clear about their scope of competence and received regular, structured clinical supervision.

We received some critical feedback from people about problems when re-ordering prescribed medicines (for example, delays in prescriptions being shared with the person’s nominated community pharmacy). The service manager told us that the service had changed the App (that people used to engage with the service online) in part to reduce these types of problems.

Medicines were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates of medicines stored onsite, including emergency medicines and vaccines. Waste medicines were recorded and disposed of appropriately including medicines returned by people. The service stored medical gases, such as oxygen, safely and completed required safety risk assessments. Staff managed prescription stationery appropriately and securely.