Testvale Surgery Also known as Dr Entwisle and Partners

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 75 (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. Staff felt there was an open culture, and that safety was a top priority. The provider had procedures in place for staff to report incidents, near misses, and safety events, and all staff members were familiar with how to use the system.

There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support in line with the duty of candour. Leaders encouraged staff to raise concerns when things went wrong. During staff meetings, the whole team discussed and learnt from clinical issues. Learning from incidents and complaints resulted in changes that improved care for others. For example, there was a data breach, which was investigated by the service and actions taken as a result. Additional steps were taken to ensure new staff complete data security training prior to receiving access to the clinical systems to prevent similar incidents in the future.

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.

The service worked with other providers to deliver shared care and when people moved between services. The service worked in partnership with the primary care network (PCN) and other related services to address the needs of those who used the service.

A structured process was established to handle test results. A buddy system provided oversight whenever the requesting clinician or the person’s own clinician was away. The service had processes to monitor delays in referrals and had clear oversight of all urgent suspected cancer pathway referrals. A review of the service’s clinical system indicated referrals and test results were being managed in a timely manner. Clinicians also tracked their own urgent referrals by regularly auditing cases, checking patient outcomes, and assessing whether each referral met the necessary criteria and resulted in suitable diagnoses or further actions.

There were systems in place for processing information about new people registering with the service. However, there was a backlog of documents dating back 4–6 weeks. This was being worked through at the time of our visit, with updates provided regularly and additional hours worked where needed. The service used the NHS England ‘GP2GP’ system to securely transfer medical records when people changed services, allowing clinicians quick access to accurate, current information for safer care.

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, relevant to their individual roles. There were designated safeguarding children and adult leads, and staff knew who these were. The service maintained a list of vulnerable people and acted on concerns working in partnership with other organisations.

Staff demonstrated clear understanding of the appropriate actions to take if they identified safeguarding concerns or suspected that an individual was at risk of harm, including instances where regular service users appeared out of character. Relevant safeguarding alerts were documented within the service’s clinical record system to ensure staff remained informed of ongoing concerns and could respond appropriately. There were safe systems and processes to ensure children had been appropriately followed up with when they failed to attend appointments, with the service maintaining clear communication with families.

Chaperoning policies were available and accessible to staff. A mixture of clinical and non-clinical staff members had chaperone responsibilities as part of their role. All staff members had completed Disclosure and Barring Service (DBS) checks and relevant training to ensure they would be appropriate to undertake this role.

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.

People were advised on risks related to their condition and actions to take if their condition deteriorated. For example, when people contacted the service, they were given guidance on how to manage worsening symptoms, including being directed to emergency services where appropriate. Safety-netting advice was also provided during consultations with a healthcare professional.

Emergency equipment was available and maintained. The emergency trolley was well-stocked, and all items were within their expiry date. Staff could recognise when a person was deteriorating and knew what actions to take.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Contracts were in place to ensure the premises were maintained. Electrical, gas and water testing had been undertaken regularly to ensure the environment was safe. Health and safety risk assessments and audits had been undertaken and risks identified had been addressed. There was a business continuity plan to support any major service disruptions, such as IT failures, which was monitored and reviewed.

Portable appliance testing (PAT) and equipment calibration had been completed and were routinely monitored. The service had a fire evacuation plan and policy, and fire warden training had been completed by the appropriate members of staff. Scheduled safety checks were conducted on the fire alarm system, emergency lighting and equipment.

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.

The provider’s recruitment and Human Resource (HR) records met the requirements of their policy and Schedule 3 of the Health and Social Care Act 2008. Our review of 3 staff files showed appropriate recruitment checks had been completed, and records were maintained accurately. Staff received a structured induction tailored to their specific roles and responsibilities and included time for shadowing colleagues and meeting with line managers.

There were a range of clinical and non-clinical roles within the service. Training was up to date, learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence. Leaders invested in developing staff skills and supporting internal career progression. For example, a phlebotomist had been upskilled to become a healthcare assistant (HCA), and another HCA was working towards becoming a band 4 practitioner.

Regular, documented clinical supervision for non-medical prescribers took place in line with the service’s clinical supervision policy. The service also provided informal supervision opportunities through case-based discussions and peer to peer sessions.

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 service had a designated infection prevention and control lead (IPC), and staff were aware of who this was and how to escalate any concerns. All staff had completed relevant IPC training as part of their mandatory training programme. Personal protective equipment (PPE) was appropriately stocked and accessible, and clinical equipment was maintained in a clean condition.

Risk assessments and audits were completed, and actions taken to mitigate risks. For example, there was a risk assessment for the use of fabric couches in the waiting room and carpeted communal areas, with regular cleaning arrangements in place to mitigate risk of cross contamination. Cleaning schedules were in place and followed. The facilities and premises were clean, and systems were in place to prevent the spread of infection.

Staff received training in handling specimens safely and spillage kits were available if needed. All cleaning items used in the service had appropriate processes to control substances hazardous to people’s health. The service had clear processes for managing clinical waste. Waste was segregated correctly and disposed of safely in accordance with current waste management standards.

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. People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms.

Staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely. As part of our inspection, we carried out remote clinical searches and reviewed samples of care records in the service’s clinical system. These searches showed medication and long-term condition reviews were detailed and person-centred. Reviews were carried out in a structured way and considered the best interests of each person, including people with a learning disability.

Staff received regular training, were competency assessed on medicines optimisation, and felt confident managing the storage, administration and recording of medicines. Medicines and medical gases, such as oxygen, were stored safely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines.

Staff followed protocols to ensure they prescribed all medicines safely, and ensured people received all recommended medicines reviews and monitoring. The remote searches on the service’s clinical system showed medicines were managed effectively, including appropriate monitoring for people prescribed high-risk medicines and disease-modifying antirheumatic drugs (DMARDs), in line with national guidance. For example, out of 62 people prescribed medicines such as Methotrexate, none were overdue for blood test monitoring. The provider had effective systems to manage and respond to safety alerts and medicine recalls and worked with the primary care network (PCN) pharmacist to ensure these were shared appropriately.

Data showed the service prescribed slightly more 3-day antibiotics for uncomplicated urinary tract infections and multiple psychotropics than average. However, leaders monitored the situation closely, and staff audited prescriptions and reviewed antimicrobial and psychotropic data quarterly to promote appropriate prescribing and better care outcomes. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.

Prescription stationery was stored securely, but monitoring its usage was inconsistent. For example, some discarded prescriptions were not recorded as per the service’s policy. However, following our feedback, this was addressed promptly through staff training and the immediate implementation of a stricter sign-in/out system for prescription folders.