Bredon Hill 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 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 of safety, based on openness and honesty. They listened to concerns, reported and investigated them. The practice had processes for staff to report incidents. Lessons were learnt to continually identify and embed good practice. Managers encouraged staff to raise concerns that were later discussed in meetings. People felt supported to raise concerns and felt staff treated them with compassion and understanding. Learning from complaints resulted in changes that improved care for others. Representatives from the Patient Participation Group (PPG) felt the practice took concerns seriously and improvements were made to the service following feedback from the PPG.

The practice worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed and monitored. The practice worked with other providers and services to ensure continuity of care, including when people moved between different services. There were systems in place for managing incoming correspondence for patient’s medical records, including processing information relating to new patients. There were recall systems in place, including text message reminders for patients. Staff ensured pathology and blood test results were reviewed and actioned in a timely manner. Staff understood the referral system and were able to tell us about the process when dealing with referrals, ensuring they were followed up accordingly. Triage systems were in place for staff to follow. The practice had fail-safe systems in place to ensure all cervical cytology results were received from the samples sent.

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. The service shared concerns quickly and appropriately. The practice had an effective system in place for the management, oversight and reviewing of safeguarding concerns. Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. Safeguarding concerns were dealt with immediately. Staff knew how to identify, report and act when dealing with safeguarding concerns. They worked well with other healthcare professionals to ensure the concerns were addressed appropriately. Staff were aware who the safeguarding lead was. The practice maintained a list of vulnerable people that was reviewed regularly and updated. Vulnerable people were coded on their system and had alerts added to their records. Safeguarding meetings were held monthly. The practice had a chaperone policy in place to maintain patient privacy during intimate examinations. Posters were displayed in consultation rooms and waiting areas.

The practice worked well with people to understand and manage risks. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. 93% of respondents to the National GP Patient Survey felt they were involved as much as they wanted to be in decisions about their care and treatment during their last general practice appointment. This is higher than the national average of 91%. Emergency equipment was available and well maintained.

The practice detected and controlled potential risks in the care environment. The practice had procedures to ensure equipment, facilities and technology supported the delivery of safe care. Audits had been undertaken and risks identified had been addressed. There was a business continuity plan in place. Portable appliance testing and calibrations were up to date. Systems were in place to check safety equipment including fire alarms and panic buttons. Fire evacuation drills were completed. During the onsite visit, the premises were visibly clean and tidy. Cleaning schedules were in place to maintain a clean, safe environment.

The practice made sure there were enough qualified, skilled and experienced staff that worked well together to provide safe care and meet people’s individual needs. Leaders explained their recruitment processes to ensure appropriate numbers of suitably trained staff were employed to support the delivery of good quality care which met the needs of the patients.There were a range of clinical and non-clinical roles within the practice. Staff were working within their agreed areas of competence. We reviewed personnel files during the onsite visit and found that the necessary recruitment documents were accessible in the staff files. Not all staff had completed their mandatory training. Although some staff members had appraisals, they were not completed on a regular basis. At the time of the visit, sepsis training and fire safety training were not mandatory for all staff and therefore not all staff had completed these courses. The practice acknowledged this feedback and added these courses to their mandatory list. We were assured staff knew what to do in urgent circumstances as procedures were in place and reception staff could communicate with the on-call GP for additional support in an emergency. Staff were happy within their roles and were given opportunities to learn and develop whilst being supported to do so. For example, one staff member expressed an interest in copper coil insertion (a form of contraception), so the practice helped arrange further training in this area of interest.

The practice assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns promptly. The practice had a designated infection, prevention and control (IPC) lead and staff were aware of this. Staff had completed appropriate IPC training relevant to their role. Staff told us they knew their roles and responsibilities around IPC. Cleaning schedules were in place and followed to ensure the premises and equipment were kept clean. Clinical rooms had adequate provision of personal protective equipment (PPE) and handwashing facilities. IPC policies were in place and IPC audits were completed regularly and the appropriate actions were taken when necessary to mitigate any risks.

The practice made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes were made to their medicines.

We carried out remote searches of clinical records as part of our assessment to evaluate whether clinicians were prescribing a range of medicines safely. We found that most patients were appropriately monitored in line with guidance. Although monitoring of the long-term condition, hypothyroidism (when the thyroid gland does not produce enough thyroid hormone that can lead to tiredness and weight gain) and people prescribed bisphosphonate for 5 years or more (a medicine primarily used to treat conditions that affect bone density) was found to need improvement. This was raised with the provider so they could take appropriate action. Staff involved people in reviews of their medicines and helped them to understand how to manage their medicines safely. The practice had effective systems to manage and respond to safety alerts and medicine recalls.

Staff regularly checked medicine stock levels and expiry dates, including emergency medicines and controlled drugs. We found no tamper proof tags on the emergency drugs bag. Fridge temperatures were monitored daily, and staff knew what action to take if the temperature was out of range. Medical gases such as oxygen were stored safely, however the oxygen mask was not stored with oxygen tank. The practice acknowledged this. We saw evidence of clinical audits to improve patient care.