Aylmer Lodge Cookley Partnership

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 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. There were clear processes for staff to report incidents, near misses and safety events. Managers encouraged staff to raise concerns when things went wrong. Staff felt there was an open culture and felt leaders took concerns seriously. During staff meetings, the whole team discussed and learnt from clinical issues.

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 services. There were systems in place for processing information relating to new patients. There were protocols in place for managing incoming correspondence into the patient’s medical records. This was managed in a timely manner. There were appropriate arrangements for the oversight and recording of laboratory results including when a clinician was absent. We found test results were managed in a timely manner. Patient referrals to specialist services were documented in the referrals systems and patient record. The practice regularly ran searches to ensure all referrals had been appropriately sent off and actioned.

The practice worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. There were clear systems in place for the management and oversight and reviewing of safeguarding. The practice had a register for vulnerable adults and children that was regularly reviewed, updated and discussed at safeguarding meetings. Safeguarding meetings were held on a regular basis to review people at risk which included external professionals such as health visitors and school nurses. The practice acted on concerns and worked in partnership with other organisations. For example, they followed up children who attended AE and those that failed to attend their appointments.

The practice worked with people to understand and manage risks. 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.

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 practice made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked well together to provide safe care that met people’s individual needs. Leaders recognised the importance of developing their staff and supporting them to undertake additional training. We saw many examples of learning and development being encouraged. For example, 3 members of staff were given the opportunity to go on a team leader course and all receptionists had received health care navigation training. We found training was up to date and safe recruitment practices were followed.

The practice 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 received relevant training. Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions were 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 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 practice had effective systems to manage and respond to safety alerts and medicine recalls. We found the dispensary at the branch site had appropriate protocols in place for staff to follow to ensure they dispensed medicines safely. As part of our assessment, a series of patient clinical record searches were undertaken by a CQC GP specialist advisor. This included a review of the management of patients on medicines that required monitoring. We found most patients had received monitoring in line with guidance. Where patients were overdue blood tests, the practice had already recognised this and sent out invitations for them to attend for a blood test.

We found Patient Group Directions (PGDs) (written instructions to supply or administer medicines to patients without a prescription or an instruction from a prescriber) were in good order. However, our review of Patient Specific Directions (PSDs) (instructions to supply or administer a medicine to a list of individually named patients where each patient has been individually assessed by that prescriber) had gaps identified. We raised this with the practice who acted promptly to put these in place and updated their protocol. We found gaps in the monitoring of the fridge temperatures. The practice took immediate actionto investigate and provided evidence to reassure us that this had been rectified.

Effective