Stokesley 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 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 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. The practice manager had an ‘open door’ policy which enabled staff to easily raise and discuss any concerns.

Staff knew how to report safety events and incidents. The practice listened to concerns about safety, and they investigated and reported safety events. Staff attended relevant meetings to discuss these.

The practice ensured lessons were learnt to continually identify and embed good practice and improve patient care.

Staff told us learning from safety events and complaints was shared with them. They gave us multiple examples of learning which had led to improvements.

The practice worked with patients 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.

Leaders had oversight of Medicines and Healthcare products Regulatory Agency alerts received. These alerts are followed to ensure that medicines and medical devices are safe. The practice had a process in place to ensure they took appropriate action when required.

The practice had systems in place to ensure external correspondence was processed effectively and in a timely manner. They also managed referrals and test results appropriately.

The practice had a robust policy in place for Shared Care Agreements which ensured they had oversight of medication requirements and that patients received appropriate reviews.

The practice had a system of processing information relating to new patients which ensured key information was captured and available on each patient’s record.

The practice worked with patients to understand what being safe meant to them and the best way to achieve that. They concentrated on improving patients’ lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

Patients could request a chaperone during appointments. Both clinical and non-clinical staff had received training to act as a chaperone.

The practice had robust safeguarding policies and processes in place. They checked staff were appropriately following processes to ensure learning could be identified and any improvements made.

Staff had received safeguarding training appropriate to their role. They were confident in identifying safeguarding concerns and knew how and who to report them to.

The practice had a safeguarding lead who maintained a list of vulnerable people and led regular safeguarding meetings. They worked in partnership with other organisations to share relevant information and act on any concerns quickly and appropriately.

The practice worked with people to understand and manage risks by thinking holistically. They provided care to meet patients’ needs which was safe, supportive, and enabled patients to do the things that mattered to them.

The GP Patient Survey showed 97% of Stokesley Surgery’s patients were involved as much as they wanted to be in decisions about their care and treatment during their last appointment. This was higher than the local and national result of 91%. The survey also showed 94% of patients felt their needs were met during their last appointment, compared to the local and national result of 90%.

The practice ensured emergency equipment (such as a defibrillator to give a jolt of energy to the heart) was available and maintained. The defibrillator and emergency oxygen were checked daily.

Staff had completed training relating to basic life support and sepsis awareness. They knew how to recognise if a patient’s condition deteriorated and how to escalate concerns.

The practice detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The premises were fit for use. Stokesley Surgery leased space from NHS Property Services under a contract which ensured the premises were safe and maintained appropriately. The practice fulfilled their responsibilities as a tenant. They maintained regular contact with the landlord, escalating any concerns to ensure the safe care and treatment of patients.

The practice had contracts in place to ensure equipment was routinely checked and calibrated.

A Business Continuity Plan was in place which the practice reviewed annually.

The practice managed fire safety appropriately. Staff received fire safety training, and 2 members of staff were fire wardens.

Staff told us they had access to the right equipment to safely perform their role. They were satisfied with the health and safety arrangements at the practice.

Patients were pleased with the refurbishment which had taken place since our last assessment. A patient told us, “We now have vastly improved facilities and a spacious and pleasant seating area whilst waiting for our consultation.”

The practice made sure there were enough qualified, skilled and experienced staff who received effective support, supervision and development. They ensured the safe recruitment of staff by completing appropriate pre-employment checks, including obtaining the relevant type of Disclosure and Barring Service check.

Staff worked together well to provide safe care which met patients’ individual needs. They told us they had enough training for their role. All staff had completed the mandatory training required.

The practice ensured all staff received an annual appraisal. There were clear supervision and support routes in place to ensure the safe delivery of care. The practice had a clinical supervision policy in place giving clear expectations of staff and their supervisors.

The practice held a meeting each morning with the opportunity to discuss clinical cases. A staff member told us, “regular supervision discussion is available on a daily basis or at any time during the day if advice required.”

Staff told us there was also an ‘open door’ policy in place which meant “plenty of opportunity to ask for advice and support.”

Although some staff said they would benefit from more protected time to complete administration duties, perform lead role duties, and / or complete learning and development, a staff member explained, “If any additional time is required due to demand then we are fully supported to make those adjustments.”

The practice assessed and managed the risk of infection. They detected and controlled the risk of any infection spreading, and they shared concerns with appropriate agencies promptly.

Stokesley Surgery leased space from NHS Property Services which ensured cleaning schedules were in place and followed. However, the practice could request additional deep cleaning when needed. For example, after a clinic held on a Saturday.

The practice had a designated infection prevention and control (IPC) lead who completed regular IPC audits of the premises and staff procedures. IPC was discussed in clinical and nursing meetings so learning and action points from audits could be shared and considered to make improvements.

Staff had received training relevant to their role. They were confident the IPC arrangements protected staff and patients. A staff member told us, “Our IPC practice lead is excellent and has disseminated [their] knowledge and systems widely.”

A patient told us, “The premises are clean and efficiently run.”

During our visit, we observed the practice to be clean and tidy throughout.

The practice made sure that medicines and treatments were safe and met patients’ needs.

As part of our assessment, a CQC GP Specialist Advisor completed a series of patient clinical record searches. This included reviewing the management of patients on a sample of medicines that required monitoring and reviewing prescribing (including the effectiveness and quality of medication reviews completed by the practice).

Findings showed patients received appropriate monitoring for high-risk medicines. For example, patients prescribed warfarin (an anticoagulant medicine to help prevent and treat blood clots), and patients prescribed bisphosphonate (medicines to help treat osteoporosis), had been monitored to ensure the effectiveness of the medicines and identify any adverse reactions.

Findings showed the practice had systems in place to ensure relevant patients received medication reviews. However, the reviews lacked key context about what had taken place. The provider acknowledged this and took immediate steps to ensure this would be rectified going forward.

Staff had access to emergency equipment. Staff regularly checked the stock levels and expiry dates for all medicines, including vaccines and emergency medicines. The practice stored medicines securely and at appropriate temperatures.

The practice took steps to ensure staff prescribed medicines (including antibiotics) appropriately to optimise care outcomes.

Staff followed protocols to ensure they prescribed medicines safely. The practice had effective systems to manage and respond to safety alerts and medicine recalls. Staff participated in regular clinical audits which focused on improving care and treatment.

The practice had appropriate Patient Group Directions (PGDs) in place. PGDs are written instructions that allow specified, registered healthcare professionals to administer specific medicines to a pre-defined group of patients without a prescription from a doctor. However, we discussed with the provider about making the administration of this process more robust.

The practice ensured prescription stationery was managed appropriately and stored securely.