Avon Road 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.

This service scored 72 (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 effective systems to learn from incidents and improve practices. Staff raised safety concerns, investigated events, and shared learning to help embed best practice and reviewed their findings annually. Staff told us and patients feedback demonstrated they felt supported to raise concerns. Staff reviewed all incidents to ensure duty of candour was followed. All incidents were reviewed annually to identify and respond to any themes and ensure compliance with the duty of candour compliance. Safety alerts and recalls were effectively managed.

The provider had processes in place for handling new patient information and met with other agencies and completed shared universal care plans and shared care agreements to enable the delivery of care when patients moved or were treated by different services. Referrals and test results were managed promptly. There were effective safety netting processes to ensure all patients were followed up.

The practice had systems and processes in place to safeguard adults and children from abuse. Any concerns were addressed in collaboration with partner organisations. Avon Road Surgery had worked in collaboration with a fellow GP practice to create and implement a new checking and validation process to ensure that all safeguarding reports were accurately coded at the time they were undertaken. This process enabled the production of a monthly safeguarding activity report and helped to ensure the safety of vulnerable patients. Staff also attended a monthly children’s mental health meeting. Staff had completed PREVENT (to help staff to recognize signs of radicalisation and extremism) and safeguarding adults and children training to the appropriate level.

The practice had mostly effective systems to assess, monitor, and manage patient safety risks. Patients were informed about risks related to their condition and advised on actions to take if their health worsened. Although, emergency equipment was available, checked and mostly maintained we found two of the oxygen masks were out of date for use during the site visit, these were immediately replaced. The deputy practice manager stated that staff were to provide further training about sepsis at a practice meeting.

The premises were leased and most of the maintenance and cleaning was carried out by the landlord. The staff detected, controlled and reported any potential risks in the environment. They made sure equipment, facilities and technology were maintained and supported the delivery of safe care.

The leaders followed safe recruitment procedures. The leaders had systems in place to mostly demonstrate staff had the necessary skills, knowledge, and experience for their roles. However, the practice submitted a record of the completion of mandatory training which showed gaps in completion, this was immediately reviewed and rectified by the practice. Staff had completed training to support people with specialist needs.

The staff effectively assessed and managed infection risks. The cleaning was carried out by the landlord. Staff promptly identified and controlled potential spread, sharing concerns with the landlord and any relevant agencies. A designated infection prevention and control lead was in place. Cleaning schedules were followed, and regular audits and risk assessments were completed with actions taken to reduce risks. To protect staff and patients, the practice had recorded the immunisation history or clinicians, however, they had not carried this out as recommended by the Green Book Immunisation of healthcare and laboratory staff for non-clinical staff.

The practice had robust systems for the safe and appropriate use of medicines, including optimisation. Staff followed prescribing protocols, ensuring safe practice and timely reviews, and regular prescribing audits supported continuous improvement in care. Medicines and emergency medicines were stored, administered, and recorded securely, and staff managed prescription stationery appropriately.