Cumberland House 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 assessed all the quality statements in this key question. At our last assessment, we rated this key question as good. The rating remains good following this assessment.

Systems were in place to protect people from abuse and avoidable harm. We found safety was a priority, and the provider took concerns seriously. Feedback from people who used the service indicated that they felt they received safe care and treatment. The provider acted upon feedback from people and made improvements to the service in response. Safety events were investigated, and lessons were learnt to identify any shortfalls, prevent a recurrence, and embed good practice. Overall, members of the staff team provided positive feedback about staffing levels. Systems and procedures were in place to safeguard patients who may be at risk of abuse. Staff had undergone checks to ensure they were suitable for employment, and they had been provided with safeguarding training at a level appropriate to their role. Oversight of staff training ensured that staff had undertaken training to meet their roles and responsibilities. Procedures for managing health and safety and checking the safety of premises and equipment were in place. There were processes for monitoring patients’ health in relation to the use of medicines including medicines that require regular review. We found that overall medicines were managed safely. We identified some areas for improvements that were addressed by the provider during the assessment process.

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.

Processes were in place for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints, and when things went wrong staff apologised. Learning from incidents and complaints resulted in changes that improved care for others. The provider held a record of significant incidents and complaints which they used to identify themes and trends. Leaders told us how they encouraged staff to raise concerns when things went wrong. Staff feedback indicated they knew how to report a safety incident. Overall staff felt that they would be supported to raise concerns. We saw evidence of meetings with staff to discuss safety concerns and actions taken. Overall, staff told us that learning from safety incidents was shared with them.

The provider worked with people who used the service and healthcare partners to establish and maintain safe systems of care. There were systems and processes to share information with staff and other agencies to enable them to deliver safe care and treatment. The service worked with other providers to deliver shared care. The provider had processes in place for people moving between different care settings. For example, all new patients were invited for a review with a GP to discuss their health and assess the needs. When new care home residents were registered a new patient assessment and medication review were carried out. Following hospital admission, if appropriate, people were contacted for a review appointment with the GP and any changes to medication were acted upon. The safeguarding lead GP maintained a list of vulnerable patients and was alerted if the patient changed GP practice so that information could be handed over to the new GP Practice. If a person living in a care home moved there was a system to update the new care service and GP about any ongoing health and care needs. Feedback from people who used the service indicated they felt involved in decisions about treatment pathways and they reported prompt follow up care. Members of the staff team were aware of local services and support networks that they could refer patients to in order to support them with their needs and to prevent ill health. Regular multi-disciplinary meetings were held where the needs of patients with more complex needs or those approaching the end of life could be discussed. Clinicians followed care and treatment pathways for treating and referring patients to other services. Referrals to secondary or specialist care were made promptly, and patients referred under the two week wait rule for suspected cancer were followed up to ensure action had been taken. There were dedicated administrative staff to ensure letters and correspondence were reviewed and acted on efficiently.

The service safeguarded people from the risk of abuse. There were systems and processes to respond when it was suspected that people may be subject to abuse or neglect. Staff had been provided with safeguarding training and staff, including safeguarding lead staff, had a clear understanding of safeguarding and how to take appropriate action to respond to concerns. The safeguarding lead GP had protected time each week to review safeguarding concerns to enable them to provide advice to the rest of the team. Alerts were added to the patient record system when there were safeguarding concerns about a patient so that all relevant members of the staff team could readily identify this. The service held regular multi-disciplinary team (MDT) and safeguarding meetings to monitor the most vulnerable people. People were subsequently contacted to offer a review appointment, as appropriate. The safeguarding lead had set up peer support group meetings for the safeguarding leads in the PCN to discuss topical issues and learning and they acted on any issues identified to make improvements. The provider reported that there had been good feedback from other practices about the peer support group meetings.

The service worked with people to understand and manage risks. A system was in place to respond to medical emergencies. A triage system was in place to ensure medical emergencies, including those identified through online requests were responded to in a timely manner. People were advised on risks related to their condition and actions to take if their condition deteriorated. Staff were trained to identify and manage risks, for example, staff had received training in sepsis awareness. People were directed to the most appropriate clinician or service to meet their needs and this included supporting people that may need urgent care and treatment. Following alerts about medication safety the provider took steps to identify people who may be at risk and to advise them on the associated risks and give the appropriate advice. Staff were trained in the management of long-term health conditions such as diabetes and chronic obstructive pulmonary disease (COPD). A system was in place to recall people for regular checks on their health when they had a long-term condition. People who used the service were referred to services that could provide them with specialist advice to manage their condition and the risk of deterioration.

The provider had systems in place to identify and manage potential risks in the environment. They made sure equipment, facilities and technology supported the delivery of safe care. Regular checks were carried out on the premises, facilities and equipment provided. Contracts were in place to ensure the premises were well maintained. Health and safety related assessments and procedures to manage health and safety were in place. This included fire safety. An accessibility assessment had also taken place. Staff had been provided with training in health and safety related topics such as fire safety and infection prevention and control. There was a business continuity plan in place to provide guidance for dealing with a major disruption to the service, for example an IT failure. Overall, staff reported satisfaction with the work environment. Some staff feedback suggested changes that could be made to their work environment which have been shared with the provider.
 

Staff received support, supervision and opportunities to develop. All new staff underwent an induction programme and were required to undertake mandatory training within an appropriate timescale. There was a system to monitor staff training to ensure mandatory updates were completed. Staff were supported to develop their skills and learning. There were systems in place to ensure that staffing levels met the needs of the service. Overall, staff told us that they felt there were enough staff to provide safe care, and they worked effectively as a team. Some non-clinical staff told us that staffing levels could be improved. The provider made sure that staff were suitable for employment. We looked at the recruitment records for a sample of staff. These showed recruitment practices were carried out in line with legal requirements. A record of staff immunisations was in the process of being collated for all relevant staff.

The facilities and premises were appropriate to support cleaning and infection prevention. Procedures were in place to prevent the risk of infection. There were clear roles and responsibilities around infection prevention and control with a dedicated lead person. Staff had been provided with training in infection prevention and control, and they were aware of their roles and responsibilities in this. Personal protective equipment was in sufficient supply and located appropriately around the premises. Cleaning schedules were in place and infection prevention control and cleaning audits were carried out. Cleaning equipment was stored securely. The arrangements for managing waste and clinical specimens kept people safe.

The provider made sure that medicines and treatments were safe and met people’s needs. We reviewed clinical records for patients who had been prescribed medicines which required routine monitoring. Our review showed that medicines were managed safely overall and the approach to medicines reflected current and relevant best practice and professional guidance. We did note that a number of older patients who had been prescribed medicine to reduce inflammation without gastric protection therapy (medicine to protect against gastrointestinal complications) had not undergone blood monitoring at the recommended frequencies. The provider acted promptly to address this. Staff had access to emergency medicines and equipment including oxygen and a defibrillator. These were regularly checked for stock availability and to ensure they were in date. We noted some improvements were needed for the monitoring of emergency medication availability and prescription management. These were immediately undertaken by the provider. Vaccines were stored appropriately, and regular checks were carried out. The provider had effective systems to manage and respond to safety alerts and medicine recalls.