Dr H W Ng & Partner Also known as Scott Park 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 staff protected people from avoidable harm and made sure care was delivered from environments that were clean and well maintained. At our last assessment, we rated this key question as good. At this assessment, the rating has changed to requires improvement.

The service did not always effectively mitigate and control potential risks within the care environment. The service assessed and managed the risk of infection, although risks identified within audits were not always actioned. Staff were qualified, experienced, and received training, although gaps were identified.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

The service did not always detect and control potential risks in the care environment. They did not always make sure facilities supported the delivery of safe care.

The service had some contracts to ensure the premises was maintained. Staff and leaders completed health and safety risk assessments and undertook audits to identify and manage risks. However, ligature risks had not been adequately identified, assessed or mitigated within consultation and treatment rooms. Window blind cords presented an avoidable ligature risk. Following our visit, the service advised they had written an action plan to replace or modify blinds to minimise risk.

The service had undertaken internal fire risk assessment safety checks, however, these had not identified a number of fire safety risks. During our site visit we identified gaps in the management of fire safety, for example, there were no fire alarms in the building, however one smoke detector was seen. In addition, there was no evidence that regular fire drills had been undertaken or documented. Following the concerns we raised during our visit, the Provider commissioned an external fire risk assessment. This identified several high and medium priority actions indicating the provider’s existing fire risk assessment arrangements had not been sufficient to identify and mitigate all relevant fire safety risks.

We also identified environmental concerns regarding the security of prescription stationery. During the assessment prescription stationery was observed unsecured in a printer within the nurse’s room. Staff we spoke with were unable to clearly explain the arrangements for securing prescription stationery.

The service had a business continuity plan which was regularly reviewed and outlined how the service should continue to operate in the event of a disruption.

The service did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

The service employed staff in a range of clinical and non-clinical roles, which included GPs, a nurse and receptionists. The service also worked with the Primary Care Network (PCN) and worked with PCN staff such as first contact Physiotherapist, Nurse Associate and a Clinical Pharmacist. Leaders ensured staff were up to date with training the service had deemed mandatory and operated within their agreed areas of competence.

The service followed safe recruitment procedures when employing staff, which were in line with national legislation. This included identity checks, review of qualifications, obtaining of professional references and a Disclosure and Barring Service (DBS) checks for clinical staff. Non-clinical staff did not have a DBS check. The provider had risk assessed which deemed chaperones will not be left alone.

Although the Chaperone Policy deemed that staff who chaperoned were not to be left alone with the person they chaperoned, staff we spoke with told us they were left alone. Leaders told us staff who chaperoned were given a copy of the chaperone policy at induction which they discussed and signed. Staff we spoke with who chaperoned told us they had not received training.

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

It was highlighted the provider’s IPC audits included damaged lino flooring visibly peeling away in the nurse’s room and carpeted flooring was present in all clinical rooms. This was acknowledged by the provider however no actions were taken or risk mitigations put in place at the time of the visit. The service has since provided us with an action plan to act on the risks identified to replace the flooring in the nurses room. During the assessment staff told us the previous steam cleaning of the carpet flooring had been carried out approximately two years ago. Following the assessment, the service has undertaken a proactive approach and submitted an action plan detailing how these issues will be addressed.

During our visit the premises and equipment reviewed were visibly clean and staff had completed relevant IPC training. However, the provider’s arrangements for monitoring and acting on all environmental IPC risks, including conducting regular risk assessments and audits for risks were not always effective or acted on.

The service had an identified infection prevention and control (IPC) lead, daily cleaning schedules were in place, IPC policies and audits which outlined how staff should clean the building and its equipment.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.