Southfield Way 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

The service had a learning culture and people could raise concerns, but action taken was not always effective. Leaders investigated incidents but did not always action these appropriately or provide an apology to patients. Staff understood and managed risks. Improvements had been made to the facilities and the equipment to meet the needs of people. The practice was clean and well-maintained, and actions had been taken since the last assessment to mitigate most risks. However, there were a number of concerns that the Care Quality Commission (CQC) identified in relation to providing safe services. These included the management of prescription security, oversight of emergency medicines and safe storage, the authorisation of written instructions for administering of medicines and the safe recruitment practices. Following our site visit, the provider sent us information confirming the action they had since taken to mitigate safety risks to ensure people were protected and kept safe. Leaders made sure staff received training and were in receipt of regular appraisals to maintain high-quality care. Staff followed processes to ensure people prescribed medicines with specific risks received the recommended monitoring and involved people in planning any changes. However, our clinical searches identified some aspects of the ongoing monitoring of people with long-term conditions needed to be further strengthened. Following our feedback the practice took immediate action and provided us with a plan detailing the action they had since taken to ensure treatment plans were effective and any adjustments were made.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not always have a proactive culture of safety. Concerns about safety were reported and investigated but not always recorded or actioned appropriately. Lessons were not always learnt to continually identify and embed good practice. Staff were aware of the process for raising a significant event and were able to share a recent event and told us these were discussed practice wide. An overall record of events was maintained; however 1 event had not been recorded and 2 other events involving personal data breaches had not been reported to the appropriate body as required. In 1 case there was no record that the patient had been made aware of the breach in line with duty of candour.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. A representative from the Patient Participation Group (PPG) felt the provider was open and honest and took concerns seriously and made improvements to the service. Leaders encouraged staff to raise concerns when things went wrong, and these were shared and discussed practice wide. Most staff felt there was an open culture, and processes were in place for staff to report incidents, near misses and safety events.

There was a system to record and investigate complaints. However, the documentation required further development in relation to responses, outcomes and ensuring people were advised of the escalation route if they were dissatisfied with the outcome or the management of their complaint. Informal complaints were not always used in conjunction with the written formal complaints, which could have led to missed opportunities for trend analysis and early identification and mitigation of risks. Following our site visit the provider sent us information about how they would improve the management of their complaints ensuring all steps were documented. They told us a trend analysis of complaints were completed monthly and shared in governance meetings.

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. Systems were in place to ensure referrals and test results were managed promptly. The storage of patient paper records had been reviewed and actions taken to ensure they were held securely.

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.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations. The Care Co-ordinator maintained a detailed child protection register which included the name, age, address, date added to the register, household members and if they were coded on the clinical system, social worker details, information when they were last seen and any additional notes. The register was regularly reconciled with the Local Authority (LA) and any amendments updated. Regular meetings were held between the care co-ordinator, social prescriber and external agencies including the community nursing team and local hospice to discuss vulnerable people and any changing needs.

The practice worked with people to understand and manage risks. However, they did not always provide care to meet people’s needs that was safe. Emergency equipment and medicines were available however, checks carried out on these medicines was not effective. We found 2 items were out of date and medicines and equipment was not held securely. Following our site visit the provider sent us information which demonstrated they had addressed these matters.

Staff could recognise a deteriorating patient and knew of action to take. Patients we spoke with told us they were advised on risks related to their condition and actions to take if their condition deteriorated.

Improvements had been made to ensure equipment and facilities supported the delivery of safe care. These included the replacement of some furnishings for example wipeable seating in the waiting area, ergonomic seating for staff and new fire doors. Contracts were in place to ensure the premises were maintained and records of checks undertaken were held. Staff reported the new practice manager had made a number of changes since they took up post, including reviewing health and safety documentation.

Health and safety risk assessments and audits had been undertaken and any risks identified had since been addressed. There was a business continuity plan in place, which was monitored and reviewed. Leaders told us they encouraged open communication and reporting of safety concerns without fear of retribution. Staff we spoke with confirmed they had no health and safety concerns.

There were a range of clinical and non-clinical roles within the practice. The provider told us they had conducted a thorough assessment of the practice’s staffing needs based on patient demand, service requirements, and peak times. A regular locum GP had joined the practice in April 2024 and provided 5 morning sessions per week, which had improved continuity of care for people. Concerns continued to be shared with us about the availability of clinical staff on site between the morning and afternoon sessions to respond to patient and staff needs. The provider told us they had robust arrangements to ensure patient safety and access to clinical care when the GP was offsite, and that practice staff could immediately telephone the GP if needed.

Staff told us they would welcome additional staff to compliment the team. Suggestions included a female GP, a full-time or deputy practice manager, additional nursing hours and a further receptionist. Following our site visit the provider sent us information and told us they had since recruited an assistant practice manager to cover the practice manager and reception during annual leave and sickness and a female GP was due to commence in July employed through the Additional Roles Reimbursement Scheme (ARRS), a government initiative that provides funding to Primary Care Networks (PCN) to support the recruitment and retention of new healthcare professionals within their teams.

Staff worked together to provide safe care that met people’s individual needs. Improvements had been made to ensure staff received support, supervision and development. Training certificates were available on individual training files sampled and these covered a range of essential and role specific training. Staff told us they were supported with learning and development opportunities. The provider told us since the last assessment they had appointed a lead for staff induction and had developed a structured induction process to help new staff to understand their roles, the practices’ culture and essential procedures. Staff induction records were available on the files we sampled; however, some of these records were incomplete. Documented clinical supervision (sampling and review of consultations) for specific clinicians were in place however, these were not always legible and were not signed and dated by both parties. Following our site visit the provider sent us information and told us that staff induction records had since been reviewed and outstanding induction had since been completed. They told us that going forward clinical supervision records would be typed to improve legibility and would be signed and dated by both parties to confirm findings and discussions had.

Records to support safe working practices were much improved. Files sampled were well presented and information was readily accessible. However, the practice was not working in line with their recruitment policy. Checks carried out by the Disclosure and Barring Service (DBS) had not been obtained prior to staff commencing work. A risk assessment had been carried out in the interim to ensure these staff were suitable for their work. Routine immunisations were not readily available on the staff files sampled however, some information was provided during and post our site visit. No written agreement (contract) was available for the locum GP who was employed in April 2024. Following our site visit the provider told us that a contract was now in place.

A new designated infection, prevention and control (IPC) lead was in place and staff had received IPC training and had access to an IPC policy, which had been updated. An internal audit had been carried out in July 2024 and an external audit was planned. Staff had access to personal protective equipment (PPE) and arrangements were in place for the disposal of clinical waste. An external company was responsible for maintaining the cleanliness of the premises and schedules were completed.

The practice was found to be visibly clean and tidy during our site visit and people we spoke with expressed no concerns relating to the cleanliness of the practice. New wipeable chairs had been obtained in the waiting area for ease of cleaning. However, not all boxes used for the safe disposal of medical sharps like needles and syringes were signed or dated when assembled as required. Following our site visit the provider sent us information and told us they had since implemented a sharps box log for each room for staff to record when they had completed this. A legionella risk assessment had been undertaken since the last assessment to mitigate risk to patients and staff.

People were involved in the review of their medicines and staff helped them understand how to manage their medicines safely. During our site visit, people shared their experiences of prescriptions and medicines. Those who required them told us the team were helpful, and their experience of obtaining these was positive.

There were systems in place to manage and respond to patient safety alerts and an electronic log of alerts was maintained. Staff received training to support them in their role and to provide safe and effective care to patients. Where appropriate, clinical staff now received monthly supervision to review their prescribing competence. However, staff did not always manage prescription stationery safely or securely. We found 18 out of 33 (54%) of patient group directions (PGDs), (written instructions to help qualified health professionals supply and administer medicines to patients), were correctly signed, authorised and dated. The remaining PGDs were missing key elements including no authorisation or had been signed after the authorisation date. There was confusion regarding which PGDs were in use as archived ones were in the same folder and the practice was unsure of the retention period for these. Following our site visit the provider told us they had since implemented monthly stock checks on prescription stationary and had now restricted access to authorised individuals only. They also told us about the action they had taken, however this was not satisfactory to achieve compliance with the safe management of PGDs.

There were protocols in place to ensure staff prescribed medicines safely and to ensure people received the recommended medicines reviews and monitoring. Medicines in the event of a medical emergency were held, and systems were in place for checking the stock levels and expiry dates. However, we found dates on 2 medicines had expired and medicines and equipment were not held securely. The provider has since taken action to address this shortfall.

Staff stored medical gases, such as oxygen, safely. The provider had systems to manage and respond to safety alerts and medicine recalls. Processes had been improved to ensure people prescribed medicines with specific risks received the recommended monitoring. Prescribing data reviewed as part of our assessment identified the number of antimicrobials issued by the provider was significantly higher than local and national averages. The provider told us they provided a primary care service to 250 elderly care home patients, and that a large number of these people had dementia and psychiatric illness and were under the care of psychiatric teams. They advised us they were unable to refuse to prescribe specific medicines when patients had been instructed to take them by the consultant psychiatrist. They also told us that these patients were vulnerable, had low immunity and at high risk of sepsis.

Following a recent breach in the cold chain leading to a remedial notice being served by the Integrated Care Board (ICB), measures had since been put in place to improve the management of vaccines and satisfy the requirement of the notice.

The practice had carried out a range of clinical audits of their prescribing practices. However, improvements were needed to ensure audits had a clear purpose, that learning, actions and outcomes were clearly detailed, and these were revisited to see whether any changes had resulted in an improvement in patient outcomes.