Ashley 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 staff protected people from avoidable harm and made sure care was delivered from environments that were clean and well maintained. At our last assessment, we rated this key question as good. At this assessment, 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.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

The service mostly detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The service had property contracts in place to ensure the premises was maintained. Staff and leaders completed health and safety risk assessments and undertook audits to ensure they had identified and addressed all risks. The practice worked with an external company to put in place local risk assessments such as new and expectant mothers, slips and trips and manual handling. The service maintained a proactive approach to safety by completing regular fire risk assessments and conducting routine fire drills led by trained fire marshals. When key lessons were identified they were shared across the team.

The service had a business continuity plan which was regularly reviewed and outlined how the service should continue to operate in the event of a disruption. However, it did not contain details of the actions to be taken in the event of cyber-attack. Following our assessment, the provider added this to their business continuity plan and developed a dedicated cyber-attack policy. We found that blind hoops were not always secured to walls in line with national alerts. Following our assessment, the provider sent us photographic evidence that the hoops had since been secured to walls.
 

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 service employed a range of clinical and non-clinical roles, which included GPs and nurses. Leaders ensured staff were up to date with their training which the service had deemed mandatory and operated within their agreed areas of competence. The service followed safe recruitment procedures when employing staff, which were in line with national legislation. This included identity checks, review of qualifications, obtaining of professional references and a criminal records check.

Recent staff vacancies at the practice had been successfully addressed through the recruitment of new staff. A newly employed staff member told us they had felt fully supported in their new role. They told us they were given protected time to complete required training and underwent competency checks before working independently. A non-medical prescriber confirmed they received regular clinical supervision to support their prescribing practices however, this supervision was informal and undocumented. Following our assessment, the provider developed a policy outlining the process of audit and clinical supervision for non-medical prescribers.

The service mostly assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. Staff had received appropriate immunisations to protect them against potential healthcare acquired infections.

During our onsite assessment, we found that the service's building and equipment were visibly clean. Staff had completed all the necessary training in infection prevention and control (IPC). Safe systems were in place for handling hazardous materials including The Control of Substances Hazardous to Health (COSHH) risk assessments. Domestic cleaning schedules were in place however, a system of monitoring that cleaning was completed in line with the schedules was not. Following our assessment, the provider sent us an action plan which included the introduction of weekly spot checks of domestic cleaning by the IPC lead. Cleaning schedules for clinical rooms and equipment were not in place for clinical staff during our assessment. However, the provider showed us schedules they planned to implement and were also exploring the use of QR codes to record that cleaning had been completed. New sinks and taps, compliant with IPC national guidance, had been fitted throughout the practice. However, a few of the older sinks with overflows had not been removed meaning they were non-compliant and a potential IPC risk. Following our assessment the provider sent us a risk assessment to mitigate potential risks and evidence they had contacted the landlord to request they be removed.

The service mostly made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning and mostly ensured that people received evidence-based, clinically effective and safe prescribing.

Vaccines were stored and transported appropriately within the practice and staff were aware of the actions to take in the event of a cold chain breach. However, systems for storing medicines that required refrigeration were not always adhered to. We found gaps when the fridge temperature within the dispensary had not been checked. Staff were unable to explain the gaps.

Our review of clinical records, prescribing data and medicines governance processes mostly provided assurance that medicines were managed effectively. Most patients prescribed high-risk medicines were up to date with monitoring, however, a small number were not. For example, we found monitoring for a small number of people was not always completed at the expected intervals for people prescribed medicines used in the treatment of high blood pressure. People who had failed to attend for monitoring had been recalled by the practice and the provider had recently put in place an escalation process for consistent non-compliance. However, the policy had not been fully implemented or embedded into practice. The provider told us they would continue to embed the policy onto practice.

Records did not always demonstrate that appropriate action has been taken in response to patient safety alerts. For example, 2 patients prescribed medicines associated with specific risk in women of childbearing potential had not been provided with the required risk information. The provider took action following the assessment and confirmed that this information had subsequently been shared and would be reinforced during future medication reviews.

Although medicine reviews had been coded, they did not always demonstrate a comprehensive review of all patients’ prescribed medicines. Medicine reviews undertaken as part of long-term condition monitoring did not always include discussion of all the prescribed medicines. This was judged to be a low risk to people. Following our assessment, the provider told us that comprehensive medicine reviews of all the medicines taken would be documented and reviewed by a clinician. Patients taking more than 10 medicines, or had more complex needs, would be escalated to the duty GP for a further review.

We found that staff received regular training and competency assessments in medicines optimisation. People were actively involved in decisions about their medicines through regular reviews and were provided with information to help them understand how to manage their medicines safely. This included emergency medicines, controlled drugs, medical gases and vaccines.

Prescribing data reviewed as part of our assessment showed that the prescribing of antibiotics was comparable with other practices. The prescribing of medicines used in the treatment of poor sleep or poor mental health was below the national average. The provider had a programme of regular clinical prescribing audits that focused on improving care and treatment.

The practice operated a dispensary, which meant people could collect their medicines from the practice or have them delivered via a local delivery service. Dispensary staff received appropriate training for their role and followed suitable processes when preparing and dispensing medicines. Governance processes mostly supported the safe and effective operation of the dispensary. We found that several of the dispensary policies lacked detail. Following our assessment, the provider took action to update their Standard Operating Procedures to strengthen medicines management processes and support the safe handling of medicines.