Francis Grove 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 remains the same.

This service scored 78 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety, 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 practice.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. Representatives from the Patient Participation Group (PPG) felt the provider took concerns seriously and proactively made improvements to the service. Managers encouraged staff to raise concerns when things went wrong. During staff meetings, the whole team discussed and learnt from clinical issues. We saw copies of staff meeting minutes from various staff groups such as clinical meetings, reception staff meetings and general staff meetings. The minutes from all of these meetings evidenced that incidents were discussed and learning shared. Most staff felt there was an open culture. All staff indicated that safety was a top priority.

The provider had processes for staff to report incidents, near misses and safety events. We reviewed a recent safety event regarding an error in record keeping. The practice took the appropriate action to rectify it once it was identified. They reviewed the incident and changed procedures within the practice as a result of this. They shared the learning from this with all staff groups, so everyone was aware of what had happened and how it was resolved.

There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. We reviewed the complaints log and saw they were responded to in line with our expectations. 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. 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. Staff told us that a spreadsheet was maintained with details of all new patients. There was a dedicated member of staff who summarised new patient notes.

The service worked with other providers to deliver shared care and when patients moved between services.

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.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. All clinical staff had completed safeguarding training to level 3 and non-clinical staff completed to level 2.

The practice maintained separate list of vulnerable adults and children and acted on concerns working in partnership with other organisations.In addition to this they maintained “Safeguarding Registers” which were to monitor adults and children who were on local authority safeguarding plans or patients that the practice felt may be at risk of progressing to safeguarding concerns.

The service 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 was available and maintained. Staff made regular checks to medicines and equipment, although improvements were needed with regard to ensuring the checks to equipment were conducted weekly in line with resuscitation council guidance.

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 care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The practice did not own the premises. However, they had processes in place to have oversight of the contracts the landlord had in place, to ensure the premises were maintained. An external company undertook health and safety risk assessments and audits. The practice had systems in place for staff to make regular checks to fire and electrical safety. There was a business continuity plan in place which was monitored and reviewed.

The service 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.

There were a range of clinical and non-clinical roles within the practice. All the staff we received feedback from told us that colleagues worked well together and were always willing to cover periods of annual leave and sickness. Whilst there were no vacancies at the time of the assessment some staff indicated that there were pressures in some areas and staff felt more resources were needed. The managers we spoke with said that they understood staff concerns and were looking at different ways of working to alleviate some of the pressure.

We found training was up to date, learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence. 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. We reviewed training records and saw that staff were up to date with training and relevant staff completed training annually.

Cleaning schedules were in place and followed. An external cleaning company carried out the domestic cleaning. The schedules outlined the daily, weekly, fortnightly, and monthly tasks that were required. Staff told us that they monitored the performance of the contractors and addressed any required improvements during meetings which they held regularly with them. We were given example of areas of improvements identified by the practice and changes implemented by the contractor as a result.

Risk assessments were completed when necessary. For example, the practice had carried out a risk assessment due to them not being able to carry out their annual audit in the usual way because of the ongoing building works.

Audits were completed regularly, and actions taken to mitigate risks. For example, we saw that the nurses completed infection control audits bi-monthly as well as annually. These audits were very comprehensive and had actions which we saw were always actioned in a timely manner.

During our inspection despite the practice undergoing major renovation, the practice was clean and tidy with no infection control concerns identified.

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. Our clinical review found that patient records documented their involvement and that reviews were completed in a timely manner. 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. There was a comprehensive prescription storage policy which detailed how they maintained a register to track prescriptions and procedures in relation to ensuring they were secure. We found that staff acted in accordance with the procedure.

Staff followed protocols to ensure they prescribed all medicines safely, and ensured people received all recommended medicines reviews and monitoring. Our review of prescribing for patients on medicine for conditions such as diabetes or for blood thinning found that prescribing was done in a timely manner and was reviewed appropriately. They also had a robust system in place to monitor patients on controlled drugs. The practice pharmacist was currently doing an audit of this ensuring they were monitoring patients appropriately. They had also revised their prescribing policy to better manage controlled drugs on repeat prescription to ensure the prescribing was appropriate. For example, they acknowledged there were some exceptions where Controlled Drugs may be on a patient’s repeat medications list, the practice ensured the justification for this was clearly documented so staff were aware

Medicines including controlled drugs 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. We saw logs of fridge temperature checks for fridges that stored medicines and checks staff carried out to monitor expiry dates of medicines.

Waste medicines were recorded and disposed of appropriately including medicines returned by patients. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments.

The provider had effective systems to manage and respond to safety alerts and medicine recalls. The practice manager was responsible for disseminating them depending on what they related to. We discussed recent alerts and saw that they were shared and acted on appropriately. All medicine related alerts were shared and discussed with the pharmacist, who also maintained a spreadsheet and actioned alerts when required. Staff also told us that relevant alerts were discussed at the clinical governance meeting. We saw meeting records to confirm this.

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 in line with the local and national averages. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.