Abbots Bromley 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 remains the same.

This service scored 69 (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 mostly detected and controlled potential risks in the care environment. They mostly made sure equipment, facilities and technology supported the delivery of safe care.

The service maintained appropriate contracts to ensure the premises were kept in good condition. Safety checks including Legionella monitoring, electrical safety inspections, gas safety certification, Portable Appliance Testing (PAT), and equipment calibration were completed in a timely manner. Annual fire safety drills were also completed in line with requirements. Fire extinguisher maintenance checks were slightly overdue; however, a date had already been scheduled to complete these in the near future.

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

A system was in place for recording prescription stationery upon receipt at the practice, and only one printer was in use to reduce the circulation of prescriptions within the premises. However, there was no system for tracking prescription stationery throughout the practice. Staff were not aware of sequencing of stationery and the key to the cupboard to where boxes were stored, there was no restricted access. After our site visit, leaders informed us how they planned to mitigate these risks.

Open access to the dispensary was observed during the inspection. This area had not been risk assessed in relation to lone working by external contractors within the building. Leaders acknowledged awareness of this risk and advised that actions had been planned; however, these had not been implemented at the time of the inspection. Following the inspection, leaders confirmed that appropriate measures had been taken to mitigate the identified risk.

The practice had spill kits available and risk assessments in place for the control of substances hazardous to health (COSHH). COSHH products were stored in locked cupboards. However, we observed one of the cupboards not locked. Leaders told us the lock had recently broken and following our onsite visit they had removed the COSHH from this cupboard.

The service mostly made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The service employed a range of clinical and non-clinical staff, including GPs, nurses, and healthcare assistants. Clinical staff we spoke with reported that they did receive supervision; however, this was not documented, and there was no established system in place to audit the prescribing practices of non-medical prescribers or to oversee clinical supervision. Leaders informed us that a system had been developed to address these gaps. We reviewed evidence of this system and were advised that it was due to be implemented imminently.

Not all staff were up to date with training that the service had identified as mandatory. While the practice acknowledged this issue and advised that processes were in place to remind staff to complete their required training, our findings indicated that these processes required strengthening to ensure all staff remained compliant with mandatory training requirements.
We found some gaps in the recruitment process. Criminal records checks had been undertaken but some documentation was lacking, for example copies of identity checks and some gaps in employment history. We spoke with leaders about this who recognised the need for a more robust system in place in this area.

Staff we spoke with told us they operated within their agreed areas of competence, and we saw this was documented so all staff within the practice had awareness of this.
 

The service assessed and mostly managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service had cleaning schedules available, for the external cleaning company but not for clinical staff. We were informed clinical staff did clean their own rooms but were not documenting this. We saw evidence that the service monitored the oversight of the cleaning agreements with the external cleaning company. The practice had a system in place to record staff immunisations.

During our onsite visit, the service's premises and a sample of equipment reviewed was noted to be visibly clean. There was readily available personal protective equipment and sharps bins were dated and closed. Clinical waste was stored appropriately.

The service’s infection prevention and control lead carried out audits to monitor compliance and took action where necessary to mitigate identified risks. However, the most recent audit identified areas requiring further improvement, and there was no documented plan outlining how these issues would be.

Some of the sinks within the clinical rooms had overflows and there was no documentation in place to mitigate the risk of this. Leaders advised that they would clarify this with the external company they employed to determine whether this risk is covered and would ensure it is recorded on the service’s new risk log.

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