Thorpe-le-Soken 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 people were protected from abuse and avoidable harm.

At our last assessment, we rated this key question as Requires Improvement. At this assessment, the rating has changed from Requires Improvement to Good.

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.

We found the practice had a proactive and positive culture of safety, based on openness and honesty. We saw evidence they listened to concerns about safety and investigated and reported safety events effectively. We found lessons were learnt to identify and embed good practice and positive outcomes for people. Staff told us they felt there was an open and honest culture, and that safety was prioritised. Staff said they were encouraged to raise concerns when things went wrong. The practice had a process to report concerns, incidents, near misses and safety events. There was a system to record and investigate complaints, and we saw evidence that learning from incidents and complaints were discussed at team meetings and actions taken had resulted in changes that improved care for others. For example, an audit of complaints showed a need to be specific to each patient and not provide generic information. This was also recorded as a significant event, discussed at the staff meeting and a learning outcome with a follow-up arranged.

We found the practice had a proactive and positive culture of safety, based on openness and honesty. We saw evidence they listened to concerns about safety and investigated and reported safety events effectively. We found lessons were learnt to identify and embed good practice and positive outcomes for people. Staff told us they felt there was an open and honest culture, and that safety was prioritised. Staff said they were encouraged to raise concerns when things went wrong. The practice had a process to report concerns, incidents, near misses and safety events. There was a system to record and investigate complaints, and we saw evidence that learning from incidents and complaints were discussed at team meetings and actions taken had resulted in changes that improved care for others. For example, an audit of complaints showed a need to be specific to each patient and not provide generic information. This was also recorded as a significant event, discussed at the staff meeting and a learning outcome with a follow-up arranged.

We found the practice had a proactive and positive culture of safety, based on openness and honesty. We saw evidence they listened to concerns about safety and investigated and reported safety events effectively. We found lessons were learnt to identify and embed good practice and positive outcomes for people. Staff told us they felt there was an open and honest culture, and that safety was prioritised. Staff said they were encouraged to raise concerns when things went wrong. The practice had a process to report concerns, incidents, near misses and safety events. There was a system to record and investigate complaints, and we saw evidence that learning from incidents and complaints were discussed at team meetings and actions taken had resulted in changes that improved care for others. For example, an audit of complaints showed a need to be specific to each patient and not provide generic information. This was also recorded as a significant event, discussed at the staff meeting and a learning outcome with a follow-up arranged.

We found the practice worked with people to understand and manage risks. People we spoke with told us staff provided care and treatment to meet their needs and felt safe and supported.

Emergency equipment was available and seen to be well monitored and maintained. At our previous inspection we were concerned the temperature control of emergency medicine was not monitored for assurance it was safe for use. At this inspection we found the emergency equipment and medicine had been moved to an appropriate area and the temperature was monitored. Staff explained how they recognised a deteriorating patient and knew the action to take. The review of the patients record system as part of our inspection showed people were advised about the risks that related to their condition, treatment, and the actions to take if their condition deteriorated.

The service detected and controlled potential risks in the practice environment. Staff made sure with regular monitoring and maintenance that equipment, facilities and technology supported the delivery of safe care.

People told us they felt safe receiving their treatment in the practice environment. Health and safety risk assessments and audits had been undertaken and risks identified had generated an action plan. We were provided the evidence that identified risks had been mitigated. There was a business continuity plan in place which was regularly monitored and reviewed to ensure the information was up to date and relevant for staff to use.

The practice provided evidence their were enough qualified, skilled and experienced staff, who had received effective support, supervision and development. People we spoke with told us staff worked together 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, the learning, and development of staff was managed appropriately. Policies and procedures showed the practice supported and encouraged staff learning, development, and there was competency monitoring. Staff told us they felt confident and were working within their agreed areas of competence. Evidence seen showed safe recruitment practices were followed when new staff were employed by the practice.

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

The practice had a designated infection, prevention and control lead and all staff had had received the relevant training. Cleaning schedules were in place and followed appropriately. Risk assessments and audits had been carried out, and any concerns that had been found had been acted on to mitigate the risks.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened, this was confirmed when we spoke with people at the practice.

Staff involved people in the review of their medicines and helped them understand how to manage their medicines safely. People told us they knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms. We saw evidence that staff had received regular training, and competency checks regarding medicines optimisation. Staff told us they felt confident managing the storage, administration and recording of medicines. Prescription stationery was seen appropriately stored, audited and recorded to ensure prescription safety. Staff followed protocols and best practice clinical guidance to ensure they prescribed all medicines safely, and ensured people received all recommended medicines reviews and monitoring.

As part of our assessment, we carried out remote searches of clinical records to check how the practice monitored people’s health in relation to medicines. For example, we identified 49 people prescribed an immunosuppressant medication, 10 of the 49, people were identified as not having the required monitoring. We reviewed a sample of 5 people’s records however, when reviewing the patient records we found the required monitoring had taken place and was appropriate. At the site visit we found the remaining 5 patients had been identified and if monitoring had not been completed an appointment had been arranged. Another search found 103 people prescribed medicines which were addictive had all received a repeat appropriate review. A further search identified 18 people prescribed medicines to manage conditions like hypertension, heart failure, and chronic kidney disease, that had not received the required monitoring. We reviewed a sample of 5 people’s records and found 1 had not received the required monitoring however, an appointment had been arranged to carry out the monitoring. At the site visit we found the remaining 13 patients had been identified and if monitoring had not been completed an appointment had or been assigned to a clinician to arrange. We reviewed the quality of medicines reviews and sampled 5 people’s records. We found 2 records did not document the context for the review. At the site visit we saw the reason for the review had been added.

We found medicines including controlled drugs were stored securely, appropriately monitored in line with best practice guidance, and kept at appropriate temperatures. Dispensary staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines, vaccines, and controlled drugs. Waste medicines were recorded and disposed of appropriately including medicines returned by patients to the dispensary. Staff stored medical gases, such as oxygen, safely and completed the required safety risk assessments.

The provider had effective systems to manage and respond to safety alerts and medicine recalls. Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring.

There were appropriate standard operating procedures for staff to follow for dispensing processes.

Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotic stewardship. Prescribing data reviewed as part of our assessment confirmed this. For example, the number of antimicrobials issued by the provider showed no statistical variation compared with other GP practices nationally.

There was a programme of regular clinical audits of prescribing that focused on improving patient outcomes, care and treatment. For example, an opioid audit to identify, educate, and support patients reduce their reliance. An audit of people taking and using steroid treatments to ensure they have a steroid card to support them to recognise and identify signs and symptoms that need treatment. The card provides information about the person when they require emergency treatment from any care providers.