The Densham 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 assessment, we rated this key question as GOOD. At this assessment, the rating remains the same.

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.

We reviewed evidence of patient feedback collected by the practice There was no specific feedback related to this quality statement. However, we saw evidence the practice took account of patient views, such as from complaints and surveys, to learn from and improve the way the service was delivered. People felt supported to raise concerns and felt staff treated them with compassion and understanding.

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.

We reviewed evidence of patient feedback collected by the practice. There was no specific feedback related to this quality statement. However, the practice shared with us examples of how care and support was planned and organised with people, partners and communities in ways that ensured continuity and included patient’s feedback. The views of people who used the service, partners and staff were listened to and considered. Our observations raised no concerns.

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.

The service had policies in place which ensured that they were able to identify and contribute towards any required interventions. They achieved this by collaborating with local services and agencies where appropriate.

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 mostly managed in a timely way.

We received no specific feedback from patients on this. However, in the GP patient survey carried out in January to March 2024, 67% describe their overall experience of this GP practice as good.

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. During our inspection we saw evidence of safeguarding policies.

The service had policies for child safeguarding and adult safeguarding which ensured that they were able to identify and contribute towards any required interventions. They maintained a register for safeguarding and held regular meetings where they reviewed relevant cases. The provider worked with local services and agencies. They utilised social prescribers and the domestic violence liaison personnel to provide support where appropriate.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. Staff training records also showed that staff were appropriately trained. The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations. However, when we inspected, we found discrepancies on the number of patients on practice safeguarding register and the number of patients on the practice online system. Since the inspection, the practice has reviewed this and shared with us the accurate records.

In the GP patient survey carried out in January to March 2024, 84% of respondents said the healthcare professionals at the practice were good at treating them with care and concern during their last general practice appointment. We also reviewed patient feedback obtained by the provider, however the available information was not relevant to this specific quality statement.

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.

There were policies and procedures in place to ensure that people were able to manage risks. People were involved in the development of their care plans. Staff reviewed the care plans timely to ensure they remained safe and effective. Staff had the necessary training for emergency response including managing emergency medication and equipment.

There were arrangements in place to ensure that the environment was maintained in a way that ensured high levels of health and safety and infection control. Cleaning arrangements were outsourced through a third party whose staff were based on the same site as the practice. The practice operated from a rented building and the owners of the building provided the necessary maintenance. The practice was furnished with the necessary records of any completed work

The service made sure equipment, facilities and technology supported the delivery of safe care. There were processes in place to ensure that that the health and safety of the environment was maintained effectively. When we inspected the practice was clean and tidy.

Contracts were in place to ensure the premises were maintained. This was in place through the owners of the building who provided the required cleaning and maintenance services. They maintained the cleaning schedules and logs which the practice could access. Cleaning staff were based at site and could be provide timely response when needed out of their scheduled routines.

The majority of feedback we reviewed indicated patients had good experiences and we did not identify any concerns with staffing levels. Patients were complimentary about staff and the support they provided.

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. The provider acknowledged they had not met the requirement to ensure staff had received training in meeting the needs of people with learning disabilities or autism. They explained this was in the process of being provided via e-learning at a Primary Care Network (PCN) level but was not yet available. They had not provided interim training to ensure staff had the relevant knowledge skills and experience in this area. However, they provided evidence shortly after the site visit to show they had now actioned this and staff had received training.

There were a range of clinical and non-clinical roles within the practice. We found training was mostly up to date, learning needs and development of staff was mostly managed appropriately. However, there were some gaps in staff having received regular appraisals. The practice addressed these gaps shortly after the site visit. Although we found most staff worked within their competence, we did find examples of staff coding on clinical templates that they had completed medicine reviews erroneously. Once highlighted, the practice put an action plan in place to correct this error and make sure staff were alerted to the error to reduce the risk of recurrence. Safe recruitment practices were mostly followed. However, they were using Disclosure and Barring Scheme (DBS) checks obtained by previous employers as part of their recruitment process and had not effectively risk assessed whether this was appropriate.

We received no specific feedback from patients on this. However, in the GP patient survey carried out in January to March 2024, 67% describe their overall experience of this GP practice as good.

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 arrangements were through a third party based on site who had the responsibility of cleaning and disposing of clinical and domestic waste.

The practice carried out infection prevention and control audits and we saw evidence of this. When we inspected it was evident that a high level of cleanliness was maintained.

There were policies and procedures in place to ensure that high levels of infection prevention and control were maintained. Staff had received appropriate training relevant to their roles. The nurse was the infection prevention and control (IPC) lead and was responsible for ensuring that clinical equipment was cleaned at the required intervals. Managers carried spot checks to help maintain high levels of cleanliness within the practice.

We reviewed the feedback received by the practice (through complaints, compliments, NHS friends and family results) as well as information shared with CQC by people who used the service. Generally, the feedback did not relate to this quality statement. However, when we carried out clinical searches, we found evidence that staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely.

Staff received regular training on medicines management, and felt confident managing the storage, administration and recording of medicines. There were protocols in place to ensure prescription related stationery was kept securely. Emergency medication and accessories were kept in an accessible place to ensure ease of access during an emergency. We saw evidence of staff carrying out medication audits with a view of improving patient safety and outcomes.

Staff managed most medicines safely including emergency medicines, and vaccines. Staff showed how they disposed of expired or unwanted medicines that patients had returned. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments. However, when we inspected, we also found some expired medication in the refrigerator. Staff immediately addressed this by removing the expired medication from the refrigerator.

The provider had effective systems to manage and respond to safety alerts and medicine recalls. Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring. There were suitable processes for staff to follow when prescribing and reviewing medicines. However, there was also evidence that reviews where not always coded appropriately on the computer system. The practice has since reviewed this and updated their processes to address the concerns we identified.

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 auditing of prescribing that focused on improving care and treatment.