Woodhall Spa New 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

At our last inspection, we rated this key question as good. At this assessment, the rating was good. Medicines management was well controlled and thorough. They appropriately managed safeguarding concerns. There was not a robust system in place for learning from events and actions from risk assessments were not always acted upon in an appropriate time frame.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff felt there was a supportive culture to raise concerns and felt they were treated with compassion and understanding. It was not evident that all incidents that occurred were appropriately recorded. There was no clear system identified for reporting, reviewing or evaluating all significant events. Events were not shared with all staff and there was limited evidence that there was learning from events to improve care or practice. There was no identification of themes from events raised. Complaints were well responded to, however the policy was inconsistent and inaccurate. An example was seen where appropriate consent was not gained in relation to a complaint. The practice told us they were going to review procedures in relation to complaints and significant events and provided an updated complaints policy following our site visit.

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.

The practice took safeguarding concerns seriously. They had clear systems in place to discuss and share information to ensure patient’s safety was maintained. The practice had developed good relationships with local healthcare partners to ensure that patients were protected from avoidable harm. Staff were appropriately trained to ensure they had the necessary understanding of what constituted a safeguarding concern. A safeguarding policy was in place at the practice and was appropriate.

The practice worked with patients to ensure they were informed about any risks regarding their treatment and provided a consistent approach to this. There was a system in place to ensure the emergency equipment was well stocked and maintained. Staff responded well to deteriorating patients and all staff were aware of how to escalate such concerns.

The service did not always detect and control potential risks in the care environment. We saw evidence that a fire risk assessment had been completed and not all points on the action log had been undertakenwithin a timely manner, with some still outstanding. We saw evidence that fire alarm testing was only completed monthly. Equipment was appropriately maintained to ensure it was safe for use.

There was a good skill mix across clinical staff at the practice who were suitability qualified, skilled and experienced. There was good non-clinical support at the practice. Staff felt their leaders and managers were approachable and helpful. We did not see evidence of formal supervision always being carried out however the practice had reflected on this and carried out an audit of non-medical prescribers to assess ways to improve this aspect. Some administrative staff’s appraisals were overdue but the practice told us these were scheduled to take place by February 2025.The recruitment process for new staff members was not clear. However, since our assessment the practice provided evidence that they have produced a recruitment policy.

On the day of the on-site assessment, the practice was visibly clean. Cleaning took place daily but was not monitored by the practice. Suitable personal protective equipment was available. Staff had received appropriate infection control training. The practice had an infection control lead in place. The infection control audit was completed but did not identify issues that were present such as out of date privacy curtains and there was not an action plan seen to evidence they had considered these aspects. We found privacy curtains at the branch practice which had not been changed in an appropriate time frame which was not in line with local or national guidelines. These were replaced following our assessment.

The practice ensured medicines were stored safely and securely with access restricted to authorised staff. There were detailed standard operating procedures in place for each process in the dispensary. Blank prescriptions were recorded upon delivery, tracked and stored securely in locked cupboards or printers. Prescriptions were signed before medicines were dispensed and handed out to patents. There was a process for requesting repeat medicines and evidence of structured medication reviews. Appropriate systems were in place for the safe management of controlled drugs. The practice monitored patients on high-risk medicines. Appropriate emergency medicines and medical oxygen were available. However, one oxygen cylinder was out of date. Vaccines were stored in line with national guidance. The practice monitored the prescribing of antimicrobials to reduce the risk of resistance. Dispensary staff had received appropriate training and regular checks of their competency. Dispensing incidents and near misses were recorded and reviewed regularly. There was a process for acting on safety alerts. Patient Group Directions (a written instruction for the administration of medicines to groups of patients not previously prescribed for) were in place and up to date.