Park Green 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

The service had a good learning culture and people could raise concerns. Managers investigated incidents thoroughly, although the significant event policy was not followed. People were protected and kept safe. Staff understood and managed risks. The facilities and equipment met the needs of people, were clean and well-maintained and any risks were mitigated. There were enough staff with the right skills, qualifications and experience. Managers made sure staff received regular appraisals to maintain high-quality care, but they did not have an effective oversight system for staff training completion. Staff managed medicines well and involved people in planning any changes.

This service scored 69 (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 processes for staff to report incidents, near misses and safety events. Two incidents were recorded for the 12 months before our assessment. Staff told us there was no incident criteria for them to follow when reporting safety events. The practice provided their incident management procedure, this was reviewed in September 2024 and did not detail a criterion for incidents. We raised this with the practice who provided a further significant event policy that contained an incident criterion but staff told us they were not aware of one. We saw that the two incidents that had been reported were discussed during staff meetings and learning implemented. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Learning from incidents and complaints resulted in changes that improved care for others.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored.

There were systems in place for processing information relating to new patients. The service worked with other providers to deliver shared care and when patients moved between services. Referrals and test results were managed in a timely way.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations. Safeguarding policies were in place and known to staff, however, it was not possible to evidence that staff were appropriately trained in safeguarding procedures.

The service worked with people to understand and manage risks by thinking holistically.

Emergency equipment was available and maintained. Staff could recognise a deteriorating patient and knew of action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

The service detected and controlled potential risks in the 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 provider did not have an effective system to monitor staff training completion. The service could not evidence whether staff training was up to date. Staff told us they had not completed training needed for their role. The practice stated they had completed appraisals prior to our inspection, but these were not all written up so could not evidence that learning needs and development of staff were managed appropriately. The provider told us following the assessment that appraisals and training for all staff was monitored and up to date, however evidence for all staff was not provided. The practice told us that they were putting an action plan in place to address training needs based on the appraisals. There were a range of clinical and non-clinical roles within the practice. The practice made sure there were enough qualified, skilled and experienced staff, who received supervision. They worked together well to provide safe care that met people’s individual needs. Staff were working within their agreed areas of competence identified through their supervision. Safe recruitment practices were followed.

The service 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 had relevant training. Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions 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 involved people in reviews of their medicines and helped them understand how to manage their medicines safely. People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms. 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. Medicines were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines, vaccines, and controlled drugs. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments. The provider had systems to manage and respond to safety alerts and medicine recalls. Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring. 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 number of antimicrobials issued by the provider was lower than local and national averages.