Archived: Lichfield Grove Surgery

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• 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. 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 mitigated. There were staff with the right skills, qualifications and experience. Managers made sure staff received training and regular appraisals to maintain high-quality care. Staff managed medicines well and involved people in planning any changes.

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.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

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. 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 when they were received by the service.

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. The service maintained a list of vulnerable people and acted on concerns working in partnership with other organisations. Although there was no regular scheduled multidisciplinary team meetings, the service told the assessment team that they would contact other healthcare organisations when relevant regarding the shared care of patients.

There were systems in place to follow up people who failed to attend appointments in primary and secondary care or were frequent attenders to the emergency department.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

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.

Our assessment identified that there were a range of clinical and non-clinical roles within the practice. We found training (and training records) for staff were mainly but not always up to date (when training had occurred but not been recorded accordingly), but that learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence. Safe recruitment practices were followed.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

The service made sure 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 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 and were able to describe to the assessment team the process when using locally held prescriptions. 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 and vaccines. Staff stored medical gases, such as oxygen safely and completed required safety risk assessments. Checks by the practice ensured that equipment was fit for purpose for example the defibrillator held on site.

The service had systems to manage and respond to safety alerts and medicine recalls, although not all alerts had been monitored regularly. Clinical records searches completed by the Commission identified not all patients prescribed a specific type of medicine for diabetes had been informed of the potential risks associated with this medicine. This drug safety alert had been issued by the medicine’s regulator in 2016. We spoke with the service regarding our findings, who informed us that patients on this medication would be notified of the associated risks to being prescribed this medicine at the earliest opportunity. The service told us 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. The service had access to clinical pharmacists who supported medicine reviews for people with a long-term condition and those in receipt of multiple medicines due to several health conditions. The service undertook clinical audits of prescribing that focused on improving care and treatment.