Penistone Group PMS 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

The service had a good learning culture and people could raise concerns. Managers investigated incidents thoroughly. People were protected and kept safe. Staff understood and managed risks. The facilities and equipment met the needs of people, were clean and well-maintained and any risks mitigated. Staff had the right skills, qualifications and experience although some recruitment processes required review. Managers made sure staff received training and regular appraisals to maintain high-quality care. Staff managed medicines well and involved people in planning any changes.

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. 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, following a brief delay in making an urgent referral, the provider organised a learning event for clinical staff focused on national guidelines related to the condition.

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. Referrals and test results were managed in a timely way.

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 although checks were carried out monthly and not weekly as per Resuscitation Council UK guidelines. The business manager told us this would be amended to weekly with immediate effect. Staff could recognise a deteriorating patient and knew what 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. 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 staff were qualified, skilled and received effective support, supervision and development. There were a range of clinical and non-clinical roles within the practice and enough clinical staff to provide safe care that met people’s individual needs. The business manager told us they were in the process of recruiting an additional receptionist and reviewing administration cover arrangements. 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 mostly followed. Although all clinical staff had received a disclosure and barring service (DBS) check, not all non-clinical staff had. The practice’s recruitment policy stated all staff would receive a DBS check. However, the business manager was in the process of reviewing this and we observed actions to mitigate risks had been taken by all staff completing an annual self-declaration and a risk assessment was provided immediately following the assessment that aligned with the actions taken. Checks were in place to confirm nursing staff renewed their registration with their professional body annually. We did not see evidence this was completed for the doctors. The business manager told us a system would be implemented immediately. We did not see a risk assessment for the drivers they employed to deliver medicines to patients. The provider forwarded a risk assessment and actions taken to mitigate risks immediately following the assessment.

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 (IPC) 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 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 received regular training, were competency assessed on medicines optimisation, and felt confident managing the storage, administration and recording of medicines. Staff managed prescription stationery appropriately and securely. Staff followed protocols to ensure they prescribed all medicines safely, and ensured people received all recommended medicines reviews and monitoring. Medicines including controlled drugs were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines, vaccines, and controlled drugs, although we observed one emergency medicine to be out of date. This was immediately removed. Waste medicines were recorded and disposed of appropriately including medicines returned by patients. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments. 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 dispensing medicines. However, the standard operating procedure (SOP) for delivering medicines did not include how refrigerated items would be stored whilst being transported and what to do if delivery was not made. The provider submitted an updated SOP immediately following the assessment to confirm the arrangements that were in place. 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. For example, the number of antimicrobials issued by the provider was lower than national averages.