Elm Hayes 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.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

The service now 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 service. Safe recruitment practices were followed, for example, the provider’s recruitment and human resources records met the requirements of its policy and Schedule 3 of the Health and Social Care Act 2008. Training was up to date, learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence. Leaders invested in developing staff skills and supporting internal career progression. For example,nurses had been supported to undertake training in chronic disease management, and where a nurse expressed interest in coil fitting, the service had applied for and secured funding for them to complete this training.

Since our last assessment, the service had introduced a formal clinical supervision process and updated its policy accordingly. The service provided evidence of documented supervision sessions for staff, including discussions about prescribing. Although prescribing audits for non-medical prescribers had not previously been undertaken, these were introduced immediately following this assessment. The service updated their policy to include 6-monthly audits and provided evidence audit sessions had already been scheduled on the service’s management system with reminders in place.

The service now assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service had a designated infection, prevention and control lead and all staff had had relevant training. Risk assessments and audits, including hand hygiene audits, were completed, and actions taken to mitigate risks. Since the previous assessment, the service had implemented a risk assessment for the use of carpets throughout the premises, which clearly set out measures to reduce the risk of cross-contamination. This included identifying that consultation rooms with carpets were not used for clinical procedures, with procedures undertaken in designated treatment rooms, and establishing a programme of deep cleaning every 3 months, with a rolling schedule for the consultation rooms. The service provided evidence to demonstrate that these cleaning arrangements had been carried out as planned.

The service had cleaning schedules available, which outlined how staff should clean the building, including the external cleaning staff. The service now demonstrated how these were monitored for completion to maintain oversight of cleaning arrangements. For example, since our last assessment, premises cleaning audits were completed by the service every 3 months to manage and assess the cleaning standards and enabled timely identification of any concerns. These concerns were then reported and escalated to the cleaning contractor area manager to address with the external cleaning staff. The service had clear arrangements for managing clinical waste and waste was disposed of safely in line with current waste management standards.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.