Drs T A Underwood & M A Thompson

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 provider had a strong and open culture of safety, where staff felt confident to raise concerns and learning from incidents led to clear improvements in care. Robust systems and pathways ensured risks were well managed, safeguarding responsibilities were understood, and care was delivered safely across services. People were actively involved in managing risks, supported by safe environments, effective staffing, strong infection control and well-managed medicines, ensuring patients were protected from avoidable harm.

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 provider had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety

People felt supported to raise concerns and felt staff treated them with compassion and understanding. During monthly meetings, the team discussed and learnt from clinical issues. Some staff indicated opportunities to strengthen escalation process, shared learning and collective reflection across the wider team.

The provider had processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints. Learning from incidents and complaints resulted in changes that improved care for others. There were processes in place to share learning with all staff at the practice.

There were systems in place for processing information relating to new patients,. The practice worked with other providers to deliver shared care and support patients moving between services. Referrals, discharge letters and test results were managed in a timely way.

Medicines safety and monitoring were actively overseen and where monitoring requirements were overdue, prescribing restrictions and risk–benefit assessments were implemented alongside proactive patient communication.

There were a range of structured meetings in place to plan effective patient treatment and care. These included multidisciplinary meetings to review patients receiving palliative care, frail patients and those who frequently attended hospital services.

The provider 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 regularly reviewed. Staff were appropriately trained in safeguarding procedures, with all staff receiving up-to-date training relevant to their role and demonstrated a clear understanding of how to identify and report safeguarding concerns. Staff acting as chaperones were trained for the role.

Safeguarding information sharing was well embedded within clinical systems. Alerts and household flags were applied within the clinical system where appropriate and relevant safeguarding care plans were shared across services to ensure continuity of care.The practice maintained a comprehensive register of vulnerable patients. We noted that robust systems were in place to monitor safeguarding activity.

The provider held regular MDT discussions on safeguarding concerns and referrals, with safeguarding as a standing agenda item at monthly Multidisciplinary team (MDT) meetings. Formal safeguarding meetings were held quarterly to provide further oversight and review.

Patients identified as vulnerable were managed proactively. The provider told us they undertook monthly reviews of AE attendance data to support early identification of potential safeguarding risks.

The provider 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. Risk management was supported through structured processes, including total triage arrangements that enabled urgent requests to be reviewed promptly and vulnerable patients to be identified and prioritised.

Our clinical searches found patients had regular comprehensive medication reviews and individuals with long-term conditions received ongoing routine monitoring.

Emergency equipment was available and maintained at both sites. Staff could recognise a deteriorating patient and knew the action to take. Emergency simulation training had also been used to test and improve response times. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

Alerts were added to patient records if they had additional needs, which allowed reception staff to offer care in line with specific individual needs.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The provider held emergency medicines and equipment at both sites. There was a risk assessment completed for both sites to document and justify the rationale for not storing some of the recommended emergency medicines.

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 robust business continuity plan in place which was monitored and reviewed.

The provider ensured that facilities and equipment were safe, and that equipment was maintained according to manufacturers’ instructions. There were systems for safely managing healthcare waste.

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.

There were a range of clinical and non-clinical roles within the practice. We found training was up to date, learning needs and development of staff was managed appropriately.

The service had access to additional staff employed through their Primary Care Network (PCN). All staff had up to date training and were working within their agreed areas of competence. For example, a pharmacist, who was a prescriber had their consultations audited to ensure they were working within their scope of practice.

The practice assessed and managed the risk of infection. Infection prevention and control was discussed at all clinical meetings to ensure standards were maintained. The IPC lead also undertook monthly IPC and cleaning checks to address any identified issues in a timely manner.

The practice had a designated IPC lead, and all staff had completed relevant training. There was an IPC policy in place and staff understood their roles and responsibilities in relation to preventing the spread of infection.

Clinical waste and sharps were managed and stored safely by the practice and a contract was in place for safe disposal. Cleaning cupboards were visibly clean and appropriately stocked. There was suitable equipment in the clinical rooms including pedal bins, PPE and hand wash facilities.

A set of IPC audits were regularly completed including handwashing and the management of sharps. The resulting data was used to make quality improvements and to identify and reduce risks to patients and staff.

Staff files did not contain evidence that all routine vaccinations were in line with guidance as some lacked information about vaccination against tetanus, diphtheria and polio. The practice was later able to provide this vaccination information for some staff and risk assess for those who were unable to provide it.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely.

As part of the assessment, we conducted remote searches on the services’ clinical system and reviewed a selection of patients’ clinical records. Our review of patient clinical records showed that patients were being effectively and safely managed.

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.

Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines, vaccines, and controlled drugs. Vaccines requiring refrigeration were stored, monitored and transported in line with national guidance. We found that fridge temperatures were monitored, and appropriate actions taken to respond to potential cold chain breaches if any.

The provider had effective systems to manage and respond to safety alerts and medicine recalls.

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 antimicrobials issued by the provider was in line with the local and national averages. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.