Catshill Village 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 staff protected people from avoidable harm and made sure care was delivered from environments which were clean and well maintained. 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.

The practice detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Leaders had contracts in place to ensure the premises was maintained. Staff and leaders completed health and safety risk assessments and undertook audits to ensure they had identified and addressed all risks. The practice had a business continuity plan which was regularly reviewed and outlined how the practice should continue to operate in the event of a disruption. We saw evidence of learning from incidents such as a recent potential fire; this was used to review and update the plan, so it was always current and relevant to potential risks.

The practice 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 which met people’s individual needs.

Leaders employed a range of clinical and non-clinical roles, which included GPs, nurses, physician associate and pharmacists. They ensured staff were up to date with their training which the service had deemed mandatory and operated within their agreed areas of competence. The practice followed safe recruitment procedures when employing staff, which were in line with national legislation. This included identity checks, review of qualifications, obtaining of professional references and a criminal records check.

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 cleaning schedules available, which outlined how staff should clean the building and its equipment. Staff demonstrated how these were monitored for completion to maintain oversight of cleaning arrangements. During our onsite visit, the service's premises and a sample of equipment reviewed was noted to be visibly clean. The infection prevention and control lead conducted regular risk assessments and audits to ensure compliance and took action where necessary to mitigate any identified risks. Staff had completed relevant training in infection prevention and control.

The practice made sure medicines and treatments were safe and met people’s needs, capacities and preferences in line with national guidance. The practice delivered good medicines optimisation by mostly embedding robust, proactive safety reviews which ensured people received evidence-based, clinically effective, and safe prescribing.

Medicines were stored, prescribed, administered and monitored safely, in line with current best practice. This included emergency medicines and medical gases. Our review of clinical records, prescribing data and medicines governance processes provided assurance medicines were managed effectively.

Staff received regular training and competency assessments in medicines optimisation. People were actively involved in decisions about their medicines through regular reviews and were provided information to help them understand how to manage their medicines safely. Clinical searches undertaken by a CQC clinician identified some gaps in monitoring of medicines. For example, not all patients with asthma who had been prescribed two or more courses of rescue steroids in the previous 12 months had received the required review following each course. This affected 12 of the 659 patients on the asthma register. We reviewed 5 of these cases and found 2 patients had not received the required follow-up review.We were assured during the onsite visit that this related to the system used for monitoring and the gaps had been reviewed. Systems were in place to manage and respond to safety alerts and medicine recalls.

The provider had a programme of regular clinical prescribing audits which focused on improving care and treatment.