The Endeavour 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.

At our last assessment, we rated this key question as good. At this assessment, the rating remains the same.

This service scored 69 (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.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. Representatives from the PPG felt the provider took concerns seriously and proactively made improvements to the service. Managers encouraged staff to raise concerns when things went wrong. 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. For example, extra checks by the reception team were introduced to ensure advice and guidance requests were responded to by secondary care providers in a timely way.

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 managed in a timely way. Representatives from local care homes told us that their experience of this practice was good overall and there was open communication with the practice management.

There was some understanding of safeguarding and how to take appropriate action, but safeguarding training was not always given sufficient priority.

Staff were not always trained to the appropriate level. Practice leaders were informed of this on the day of the assessment. Following the on-site inspection, all nursing staff attended and completed the required safeguarding training. At the time of the assessment, there were plans in place for the introduction of 2 Primary Care Network (PCN) level safeguarding nurses within the following weeks. Practice leaders told us that safeguarding policies were under review to reflect the upcoming changes. Staff were aware of the safeguarding lead within the practice and knew how to contact them where needed.

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. Staff were aware of how to call for help in the event of an emergency. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

The service did not always detect and control potential risks in the care environment. The systems that were in place for staff to check the premises were not robust, for them to detect and document any findings.

An infection prevention and control audit was completed annually. We were told that the designated infection prevention and control lead completed a weekly check of the premises, although this was not a formalised or documented process. This was not recorded and any identified issues were not therefore tracked. We found 1 emergency pull cord within a patient bathroom that was not reachable from the floor in the event of a fall. Practice leaders were informed of this on the day of the inspection, and the pull cord was repositioned. Practice leaders told us that the pull cord had been pulled by a patient on the day of the inspection and that cleaning staff checked the cord each evening to ensure it was in the correct position.

Contracts were in place to ensure the premises were maintained. Fire safety logs were completed. Health and safety information was accessible to all staff.

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 logs were up to date and regularly reviewed by practice leaders. However, we found that nursing staff were not trained in safeguarding measures in accordance with expected standards. Immediate action was taken in this area by practice leadership following our assessment. We saw evidence that all nursing staff had completed the appropriate safeguarding training following the assessment. Other areas of mandatory training had been completed by all staff. Safe recruitment practices were followed. Staff reported having the appropriate training and equipment to perform their roles.

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. Risk assessments and annual audits were completed, and actions taken to mitigate risks.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

Staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely. People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms. Staff followed protocols to ensure they prescribed all medicines safely, and ensured people received all recommended medicines reviews and monitoring. Safety alerts were shared with staff by pharmacy staff. Medicines were stored securely and at appropriate temperatures. Staff regularly checked the expiry dates for all medicines, including emergency medicines and vaccines. Quantities of emergency medicines were not recorded; there was therefore no record that staff had checked stock levels of emergency medicines. Immediate action was taken in this area by practice leadership. Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring. On review of clinical records, we saw that monitoring for long-term conditions was good. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.

Our review of clinical records showed that diabetes monitoring had been completed for all diabetic patients. Practice prescribing trends had been presented to the practice by the Integrated Care Board (ICB) Pharmacy Team.