Ordsall Health 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

SAFE

At our last assessment, we rated this key question as good. At this assessment, the rating remains the same.

There were no gaps in the management of specific high-risk medicines or people who were pre-diabetic. The provider had clear and effective processes which promoted the continued wellbeing of patients.

People were involved in planning any changes in their care and treatment, including medicine optimisation.

People told us they were confident about their safety and trusted the GP’s, nurses and administration staff working at Ordsall Health Surgery.

The service was well managed the managers had processes in place to enable effective oversight of the risks and strengths of the service.

Staff reviewed assessments taking account of people’s communication, personal and health needs.

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.

Ordsall Health Surgery 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.

People who gave feedback stated their concerns were identified and dealt with.

Staff told us that managers encouraged them to raise concerns when things went wrong and felt there was an open culture. Staff frequently identified that safety was a top priority. The provider had processes for staff to report incidents, near misses and safety events.

There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support.

Learning was then shared with other departments and organisations involved.

Learning from incidents and complaints resulted in changes that improved care for others.

This was evident in changes made in dealing with test results to ensure all results are checked by a GP with a failsafe that all test results are stored in a single platform and flagged until they are resolved.

Ordsall Health Surgery collaborated with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed and monitored.

They made sure there was continuity of care, including when people moved between different services and took steps to strengthen systems when gaps were identified.

The service worked with other providers to deliver shared care.

There were regular clinical review meetings to which health visitors and other community-based health professionals were invited.

There were systems in place for processing information relating to new patient’s and leaders had recently increased and modified training for staff to ensure all relevant information was transferred between old and new records.

Referrals and test results were managed in a timely way; the leaders stipulated that that practitioners were tasked to review test results within a maximum of 24 hours of the result being returned.

Urgent tests were tracked and tagged as such. The service had introduced a new procedure for dealing with test results and this change was being monitored.

Clinical and admin leaders held a daily huddle or meeting to ensure risks for the day were identified and mitigated. The huddle also ensured managers were confident team members understood their roles in the event of specific emergencies, for example a major road traffic accident or patient collapse. The information was then shared with all staff members verbally and through updated internal communications.

Ordsall Health Surgery 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 practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations. The service shared concerns quickly and appropriately.

Safeguarding policies were in place and known to staff, who were trained to the correct level for their responsibility in safeguarding procedures.

All clinical staff had completed Safeguarding adults and Child protection training level three.

Staff had completed specialist training for working with and recognising abuse and vulnerabilities for people with learning disabilities.

Health visitors shared and provided information for clinical meeting and attended when possible.

The safeguarding lead attended and reported to multiagency safeguarding meetings as required.

The service always worked well with people to fully understand and manage risks by thinking holistically. They provided care that fully met people’s needs and was safe, supportive and enabled people to do the things that mattered to them.

People told CQC that their care and treatment was discussed with them, they confirmed doctors, nurses and other staff made sure they knew how to manage their condition and what to do if they failed to improve.

Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

We noted the provider took steps to strengthen processes to ensure continuity of care for patients transferring from another practice when gaps were found.

We observed that emergency equipment was available and maintained.

All staff had been trained in emergency first aid appropriate to their role. Staff could recognise a deteriorating patient and knew of action to take. Staff were given a specific role and prepped for responding to a medical emergency on a daily basis.

Appointment booking staff had completed triage training to ensure specific questions were recorded correctly and a triage doctor was on duty monitoring, signposting and responding to patients calls in real time if required.

Ordsall Health Surgery detected and controlled potential risks in the care environment.

The practice had full responsibility for managing the building and most equipment. There were a number of computers that were centrally provided, and leaders need to confirm who is responsible for ensuring these are checked in keeping with best practice recommendations.

Leaders had ensured the safety of all equipment, facilities and technology under their control, and so, promoted the delivery of safe care.

Contracts were in place to ensure the premises were maintained. Health and safety risk assessments and audits had been undertaken and risks identified were being addressed.

We saw that checks and calibrations needed, were up to date.

There was a business continuity plan in place which was monitored and updated as required.

We also observed that all areas, including public areas and seating looked in good repair.

Ordsall Health Surgery made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development.

Ordsall Health Surgery is a training practice for GP Registrar's in the final few years of their specialist training. Registrars generally spend between 6 and 12 months with the practice under the direct supervision of their GP trainer within the practice. There are 3 approved GP trainers who are trained and monitored by Health Education North West Deanery.

Staff worked together well to provide safe care that met people’s individual needs.

We found training was up to date, and topics were comprehensive. Learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence.

GP’s, nurses and administrators each had designated professional leads who were experts in their field. Leads were responsible for ensuring staff who reported to them were competent in their role and worked to the highest standards.

People told us staff were knowledgeable, competent and good at their jobs.

Safe recruitment practices were followed.

Staff told us they were supported to increase their knowledge and learn new skills for the benefit of patients and in response to changes in best practice guidance and new techniques.

There was continuity of care because people told us that, throughout a course of treatment, they were generally seen by the same doctor.

Ordsall Health Surgery 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 completed relevant training.

Cleaning schedules were in place and followed. Risk assessments and audits, including hand-hygiene audits, were completed, and actions taken to make improvements where needed.

Contracts were in place to ensure safe collection and disposal of clinical waste and reports confirmed that when collected waste had been packaged securely.

We observed that staff were clean and tidy and wore a uniform. This ensured they remained bare below elbows while on duty, which further promoted effective hand hygiene.

Ordsall Health Surgery had effective systems in place to promote safe medicines and treatments.

The service involved people in planning their medicines regime.

People told us that staff involved them in reviews of their medicines and helped them understand how to manage their medicines safely.

We observed processes in place concerning the storage, administration and recording of medicines and noted these would keep people safe.

Staff managed prescription stationery appropriately and securely.

As part of the assessment a CQC GP specialist advisor carried out a number of set clinical record searches to review medicines requiring monitoring. These searches were visible to the practice.A sample of patient records were checked to ensure the required monitoring was taking place. The clinical searches did not identify any shortfalls in patient medicines monitoring.

The clinical searches showed processes for dealing with alerts were in place and staff followed protocols such as responding to medicine alerts and considering best practice guidelines to ensure they prescribed medicines safely.

Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring.

The clinical searches included checking what was written for each patient during a medicine review. Medical records were in sufficient detail to confirm the care and advice provided to patients and that the correct tests had been requested.

We noted that special codes available for use, in medical records, to highlight when special attention was needed were generally applied correctly and responded to.

The provider used learning from specific incidents to identify where coding could be improved.

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. Medical gases, such as oxygen, were safely stored and required safety risk assessments had been completed.

Waste medicines were recorded and disposed of appropriately.

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 lower and so better than local and national averages.

There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.