St Mary’s 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.

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. The provider took concerns seriously and proactively made improvements to the service. Managers encouraged staff to raise concerns when things went wrong. During staff meetings, the whole team discussed and learnt from clinical issues.

Staff we spoke with felt there was an open culture, that safety was a top priority and gave examples of how to report incidents and significant events. 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.
 

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 always continuity of care, including when people moved between different services.

There were systems in place for processing information relating to new patients, including the summarising of new patient notes. There were protocols in place for managing incoming correspondence into the patient’s medical records.

The service worked with other providers to deliver shared care and when patients moved between services. Staff we spoke with described how referrals and test results were managed in a timely way and patient records were kept up to date.
 

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 relevant to their roles. Staff training was up to date and staff we spoke with were aware of systems to escalate safeguarding concerns and were able to give examples. 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. Systems, processes and equipment were in place to manage medical emergencies; including automated internal and external defibrillators, oxygen and emergency medicines. All staff were trained in basic life support and could recognise a deteriorating patient and knew of action to take. Clinical and non-clinical staff had received sepsis awareness training. 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 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 reviewed clinical and non-clinical recruitment files and found recruitment documentation in line with guidance and that safe recruitment practices were followed.

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.
 

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 relevant training. Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks. The practice manager and IPC lead performed regular checks of the premises.
 

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.

We visited St Mary’s Surgery and reviewed how medicines, including controlled drugs, were stored and managed within the dispensary. We also spoke with the dispensers and the practice/dispensary manager. The practice operated an on-site dispensary for eligible patients living in rural areas. Medicines were stored securely with restricted access. Staff managed stock effectively, with clear processes for ordering, checking expiry dates, and identifying short-dated items.

Fridges were clean, well-organised, and temperatures were being checked regularly. However, room temperatures were not being monitored. This was highlighted to the practice, who confirmed they would put a process in place to address this.

Controlled drugs (CDs) were stored securely with restricted access. Stock checks were completed regularly however documentation to support this was not always completed in line with the provider’s policy. Stock balances were accurate on the day of inspection. Further work was needed to ensure that arrangements were in place for the timely destruction of expired stock CDs. The practice acknowledged the findings and took action to address them.

The practice had clear processes for ordering, receiving, and dispensing prescriptions and staff understood these well. Staff reviewed prescriptions awaiting collection each month and we saw this was effective.

When medicines were unavailable, staff checked alternative suppliers or gave patients the option to take their prescription to another pharmacy or return to the GP for an alternative medicine.

The practice received MHRA alerts by email and acted on them appropriately, and there was a process to ensure all staff read and shared relevant safety information.

The practice had an appropriate system to record medicines errors, incidents, and near misses and share lessons learned.

Staff managed prescription stationery appropriately and securely. Staff followed protocols to ensure they prescribed all medicines safely, and made sure people received all recommended medicines reviews and monitoring. 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.

There were suitable processes for staff to follow when dispensing medicines. Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes. Prescribing data reviewed as part of our assessment confirmed this. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.

We carried out a series of searches on clinical systems as part of this assessment. These searches indicated that some patients required additional monitoring, medication reviews and several potential missed diagnosis. At the time of our inspection this had been addressed by the practice.