Dr Christopher Bark Also known as The Soho Square 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 has remained the same

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 practice had a proactive and positive culture based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good service.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. Managers encouraged staff to raise concerns when things went wrong. 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 practice worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. There were systems in place for processing information relating to new patients. The leaders explained they had oversight of the workflow tasks to ensure they were all responded to promptly.

The practice 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.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. The service shared concerns quickly and appropriately. The practice maintained a safeguarding register and appropriate alerts were places on the whole household for vulnerable patients on the safeguarding register as well as household members. There were regular meetings between the practice and other health and social care professionals, the safeguarding lead also attended regular borough wide meetings and updated the team.

The practice 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.

Emergency equipment and medicine was available, maintained, and regularly checked, with the exception of benzylpenicillin (which is an antibiotic used for bacterial infections). The leaders informed us this was recently used and that efforts were being made to replace this. Prompt action following the assessment was taken to obtain this to provide assurance that risk was minimised. Risk assessments were provided for emergency medicines that were omitted. 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

Leaders at the practice were able to detail the policies and procedures that were in place to ensure that the environment was safe. They made sure equipment, facilities and technology supported the delivery of safe care.

Contracts were in place to ensure the premises were maintained and oversight for this was with the NHS landlord. Health and safety risk assessments and audits had been undertaken. We observed fire exits were clear and fire safety equipment was easily available and regularly checked. There was a business continuity plan in place which was monitored and regularly reviewed.

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 that met people’s individual needs. Leaders informed us they had processes and systems in place to report, investigate, and learn from significant events, complaints, or incidents that occurred.

There were a range of clinical and non-clinical roles within the practice. We found learning needs and development of staff were managed appropriately, and staff were working within their agreed areas of competence. Safe recruitment practices were followed.

The practice assessed and managed the risk of infection. They ensured that facilities were safe, and that equipment was maintained according to manufacturers’ instructions. The premises were visually clean, hygienic, and uncluttered.Cleaning schedules were in place and followed. There were systems for safely managing healthcare waste.

The practice had a designated infection, prevention and control lead and all staff had had relevant training. On the day of assessment, we found that some of the chairs (8 out of 16) in the waiting area were cloth material, which poses a potential infection control risk. Leaders informed us this was provided by the building landlord, and highlighted that the practice had appropriate seating in all clinical rooms. However, the practice did not take any steps to remove the risk.

The practice worked to ensure 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. People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms. Staff received regular training, were competency assessed on medicines optimisation, and felt confident managing the storage, administration and recording of medicines. Staff managed prescription stationery appropriately and securely.

However, we identified some cases that required follow up and action by the practice. Our GP specialist advisor carried out a remote review of the clinical record system and the searches indicated that 2 out of 5 patients whose records were reviewed were overdue medication reviews for hypothyroidism, 1 patient was overdue an asthma review, and 3 of 5 patients whose records were reviewed were overdue diabetic reviews. This was due to personal lack of engagement with the practice despite prior attempts by staff that was evident on the system. Leaders informed us they were aware of this cohort of patients with some being under the mental health team. However, there were no concerns found for reviews undertaken for those over 75 years or patients on methotrexate. Following feedback relating to the clinical searches the practice made sufficient arrangements to ensure patients identified that were not up to date with monitoring were followed up. As a result of this, leaders informed us, staff attended to patients in their homes and provided the necessary support.

Medicines were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines. Staff stored medical gases, such as oxygen safely. Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes. The practice had effective systems to manage and respond to safety alerts and medicine recalls.