The Bucklebury Practice Also known as Chapel Row 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

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. However, we identified some gaps in relation to mandatory training records, including safeguarding training. The provider took action to address these issues and had taken steps to improve oversight of mandatory training.

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 practice 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.

Representatives from the Patient Participation Group (PPG) felt the provider took concerns seriously and proactively made improvements to the service based on their feedback and patient voice. 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. The provider had processes for staff to report incidents and safety events. There was a system to record and investigate complaints, and when things went wrong. Learning from incidents and complaints resulted in changes that improved care for others. Following a review of the complaints, the palliative care protocol was updated to improve communication between the practice and patient's family.

The practice had an open learning culture. There was an annual review of complaints which monitored and identified recurring themes, trends and informed quality improvement.

The practice 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.

Systems ensured that all patient information, including laboratory results and referrals, were reviewed and actioned promptly. Referrals to specialist and urgent services were managed through well-defined and consistently applied processes.

The practice worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that.

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. Safeguarding was a standing agenda item at the clinical meetings enabling clinicians to discuss new concerns, recent referrals and actions to be taken. Clear processes were in place to ensure safeguarding information was disseminated to relevant professionals where appropriate.

The practice 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.

Staff demonstrated a strong understanding of emergency protocols and had received appropriate in sepsis.

Emergency equipment was available and maintained. We noted the emergency medicines held on the resuscitation trolley were not maintained in accordance with relevant guidance. Following the onsite inspection the provider shared a risk assessment relating to the availability of medicines. The risk assessment recognised that the practice had a fully operational and staffed on site dispensary throughout the surgery opening hours which provided access to a comprehensive range of medicines, including all those recommended in national guidance. This rationale supported the practice decision on storage and availability of emergency medicines.

Staff could recognise a deteriorating patient and knew of action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

The provider 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. For example, legionella testing and portable appliance testing were carried out to ensure staff and people were safe.

Maintenance contracts were in place to maintain the accuracy of equipment, such as regular calibration. Scheduled safety checks were conducted on the fire alarm system, emergency lighting and equipment.

Safety alerts relating to equipment were effectively disseminated to relevant staff and acted upon in a timely manner, ensuring risks were minimised.

There was a business continuity plan in place which was monitored and reviewed.

The provider 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.

We reviewed 5 personnel files and found gaps in the mandatory training records for existing members of staff. At the onsite inspection there was insufficient evidence to confirm that all members of staff were up to date with the required mandatory training. For example, we noted 1 of the locums had completed Safeguarding Adults and Children training up to Level 2, rather than the Level 3 training required for their role.

We also identified there were some gaps in completion of Equality and Diversity and Mental Capacity Act training for both clinical and non-clinical staff.

The practice was responsive to our finding and provided additional evidence following the onsite visit including the updated training matrix. The practice explained the discrepancies identified were due to the issues with training system which had resulted in records not being accurately reflected. We noted that the practice shared the updated mandatory training compliance policy and had taken steps to address these discrepancies and improve the accuracy and monitoring of training records.

The provider has since strengthened their processes to ensure training records are accurately maintained and monitored to demonstrate staff compliance with required training standards.

We found that recruitment checks had been completedin accordance withregulatory requirements for staff working at the practice.

The provider 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 audits were completed, and actions taken to mitigate risks.

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

Medicines including controlled drugs were stored securely. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines, vaccines, and controlled drugs. 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.

Our GP specialist adviser carried out remote searches of the practice's clinical system. These included searches for patients prescribed medicine which require ongoing monitoring and with long-term conditions. We found that overall medication monitoring was largely effective with appropriate recall systems in place for high-risk medications, however some improvements were identified. The practice was proactive to our findings and submitted a comprehensive plan to review these patients and address the findings.

We found that systems for the management of prescription stationery were not effective. There was no audit trail or log to record the issue and the use of prescription stationery by dispensary staff. There was limited oversight, or security arrangements to minimise the risk of misuse or loss of the stationery items. However, following the inspection the provider shared an updated process for managing prescription stationery. This included a system to record prescription, monitor their use and ensure there was secure storage and reconciliation.