Southway 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 assessed all quality statements in the safe key question. At our last assessment we rated this key question as requires improvement and issued a warning notice for failure to comply with Regulation 17: Good governance.

• The providers significant learning events were not investigated in a manner that identified the cause.
• The provider did not always seek and act on feedback from staff and patients.
• There were no clear systems, policies or processes for safeguarding.
• The provider was not operating effective systems to ensure staff were appraised or supervised.
• Staff were overdue mandatory training.
• The provider had not responded to health and safety assessments which required action.
• Our remote clinical searches at the time identified patients were overdue reviews.

However, at this assessment we rated the key question as good as the provider had made the necessary improvements. We found the practice had an effective learning culture that enabled them to share learning outcomes with the whole team. The practice took concerns seriously and regularly investigated, reviewed, analysed, and learnt from events and incidents.

The facilities and equipment met the needs of people, were clean and well-maintained and any identified risks were mitigated.

There were not always enough staff with the right skills, qualifications and experience. However, the provider used locum nurses and health care assistants (HCA) to cover these vacancies. Managers made sure staff received training and appraisals to maintain high-quality care. However, the supervisions that were taking place were not documented or saved to personnel files for performance management.

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 practice had a proactive and positive culture of safety based on openness and honesty. People who used the service and staff were given opportunities to provide feedback and the practice took action when necessary. They listened to concerns about safety and investigated and reported safety events.

Policies and procedures supported and encouraged a learning culture. Staff understood how to raise concerns and report incidents. Staff told us that learning from safety events were shared with them. For example, minutes reviewed from monthly clinical governance meetings showed a cold chain (vaccine storage) breach was discussed and what actions were to be taken. This included ongoing monitoring and who was responsible for actioning the learning outcome.However, at the time of inspection not all actions were assigned to a member of staff to oversee.

We saw evidence where learning from events and incidents had been shared via an internal system. At the time of the inspection not all meeting minutes were being captured. Minutes are important as they provide an accurate record of discussion during meetings and enhances communication and ensures accountability. However, the provider have shared an action plan with us which indicated that all meetings will be minuted moving forward. Evidence of minutes have since been shared with us.

Managers encouraged staff to raise concerns when things went wrong. Staff felt there was an open culture, and that safety was a top priority. There was a system to record, investigate and track complaints along with who was responsible for investigating and taking action to address concerns when needed. When things went wrong staff apologised and gave people support.

According to NHS Friends and Family Test (FFT) people were able to raise concerns and felt staff treated them with compassion and understanding. FFT is a national initiative and is a quick and anonymous way for patients to provide feedback on the care or treatment they receive from NHS services. Representatives from the Patient Participation Group (PPG) felt the practice offered them an opportunity to share concerns. They were confident in the practices’ ability to action issues and felt listened to. However, they expressed concerns that it had been difficult to reach out effectively to patients to gain their insight on the practice. There was a plan in place to address this with potentially setting up virtual meetings to accommodate more attendants.

The practice worked with people and healthcare partners to establish and maintain safe systems of care in which safety was managed or monitored effectively. There were systems for processing information relating to new patients. The practice worked with other providers to deliver shared care when patients moved between services to ensure continuity of care. Referrals and test results were well managed. At the time of inspection there were no referrals pending for action. Referrals to specialist services were well documented. These were prioritised for routine or urgent action and contained the required information. Staff were able to explain the referral process to us and how they captured patient’s needs, wants and wishes. The referral policy was relevant and up to date with the latest standards and referred policy users to additional guidance. Staff understood the importance of continuity of care to ensure the right care at the right time, with the right member of staff.

There were safeguarding policies which were known to staff who were appropriately trained in safeguarding procedures. The practice maintained a list of vulnerable people and acted on concerns and worked in partnership with other organisations. For example, the practice would receive a notification to alert them to new safeguarding concerns from external agencies. There were regular clinical governance meetings within the practice to discuss safeguarding concerns and alerts and how these were managed. The practice was unable to reestablish external safeguarding meetings with local partners such as health visitors and school nurses on a more regular basis. These meetings currently take place every 3 months.However, the practice shared their safeguarding register with social services and health visitors, for example, and were able to flag new and ongoing risk. A partner at the practice had the safeguarding lead role and was being supported by the Primary Care Network (PCN). A PCN is a group of GP practices working closely together, aligned to other health and social care staff and organisations, providing integrated services to their local population.

Staff explained and understood how to monitor for signs of abuse. They knew how to escalate concerns and gave examples of what to look for. Staff felt comfortable raising concerns and they knew the process of how to do this. The practice had a nurse who was the lead for care and treatment for people with a learning disability and they understood restrictive practices and the importance of capturing the voice of the patient.

The practice worked with people to understand and manage risk. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Patients were advised on risks related to their condition and actions to take if their condition deteriorated. Staff could recognise a deteriorating patient and knew what actions to take.

As part of our assessment a number of set clinical record searches were undertaken by a CQC GP Specialist Advisor. These search criteria are freely available for practices to access at any time. Our clinical searches identified no issues regarding the patients of child-bearing age who were prescribed teratogenic drugs (medicines that can cause birth defects or developmental disorders). Care plans were informative and reviewed regularly. Emergency equipment was available and well maintained and risk assessments performed.

The practice effectively detected and controlled potential risks within the care environment. Health and safety risk assessments and audits had been undertaken and risks identified had been addressed. They made sure equipment, facilities and technology supported the delivery of safe care. Equipment had up to date calibrations and Portable Appliance Testing (PAT). Calibration is the process of determining if a specific piece of equipment’s measurements and performance are accurate and reliable. Clear signage was displayed around the building which supported people and staff in the event of an emergency evacuation.

Contracts were in place to ensure the premises were maintained. Fire safety was regularly checked by staff with appropriate fire risk assessments being performed by an external company. Legionella testing was scheduled for every 6 months and certification was seen to confirm this. Legionella is a bacteria which can cause breathing problems.

There was a business continuity plan which was monitored and reviewed. Staff had completed appropriate training on information governance and office and fire safety.

Staff received effective support, supervision and development. Systems demonstrated appointments were allocated to appropriate clinicians. Staff worked together well to provide safe care that met people’s individual needs. There were a range of clinical and non-clinical roles within the practice. We found training was up to date. Learning needs and development of staff were managed appropriately and staff were working within their agreed areas of competence. Staff had completed mandatory training and some had also completed specific training in their specialist area. Staff were given adequate time and support to complete their training.

Recruitment files were mostly complete with the relevant applications, references and employment history. However, full employment history together with satisfactory written explanation of any gaps in employment was not available for all recruitment files we checked. DBS checks were completed in line with requirements of staff. DBS enables employers to check the criminal records of current and potential employees to ascertain whether they are suitable to work.

During our inspection we noted that recruitment, personnel files and significant events were held in different parts of the practice’s computer systems. We discussed with the practice manager and the provider how they could streamline the system; so that these records were held in a specific place to assist with access and provide better oversight. There was an induction process for all staff and handbook provided to all new starters which contained relevant information.There was a recruitment process to ensure the right candidates were hired. However, leaders were not always following this process or guidance from their recruitment policy. Annual appraisals were being undertaken by the practice manager and a partner. However, they were not able to evidence that clinical supervisions were being carried out due to lack of minutes or records of discussion.

Following our inspection, the practice have stated going forward they will ensure supervisions are documented and stored appropriately and they were currently moving all records to one area as a priority.

The practice no longer had a designated infection, prevention and control (IPC) lead. This role was being picked up by a practice partner and the practice manager. All staff had training in line with national guidance. We saw cleaning schedules were followed. Policies and procedures were available to all staff. The premises were visibly clean. Sharps bins used to disposed of used needles were safety used and disposed of. Personal Protective Equipment (PPE) was available to staff. Risk assessments and audits related to infection control were completed.

There was a process to record staff vaccinations in line with national guidance.

The practice made sure that medicines and treatments were safe and met peoples’ needs, capacities and preferences. Our clinical searches identified no issues in the use of medicines within the practice. The practice had taken steps to prescribe safely by reducing prescriptions of antibiotics for urinary tract infections from 7 days to 3. We reviewed 5 asthma patients and found they had appropriate management of symptoms and received regular reviews in line with national guidance. Monitoring of patients with long term conditions such as chronic kidney disease (CKD), diabetes or hypothyroidism were all up to date with appropriate management.

Staff followed protocols for safe prescribing, medicine reviews and monitoring. Emergency medicines and equipment were checked regularly, stored safely and easily accessible. Medicines and vaccines were stored appropriately, securely and monitored to ensure medicines were stored within the correct 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. Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring.

Patient Group Directions (PGDs) had been authorised appropriately. PGDs provide a legal framework that allows some registered health professionals to supply and/or administer specified medicines to a pre-defined group of patients, without them having to see a prescriber (such as a doctor or nurse prescriber).

The practice had a clear process to ensure appropriate audits were taking place for the non-medical prescribers (NMP). These showed that the practice were reviewed staff competencies and areas for learning were identified and acted upon.

The process for managing safety alerts, specifically alerts from the Medicines and Healthcare Products Regulatory Agency (MHRA) were effective. The practice system audited all emails received from the MHRA. They were able to check that all alerts had been actioned and shared appropriately.

Blank prescription stationery was stored securely and a log was maintained of their use.