Catherine House 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 in April 2022, we rated this key question as Inadequate. We served a Warning Notice for breach of Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 – Safe care and treatment.

During our responsive follow up assessment in September 2022, we assessed that improvements had been made but we did not re-rate the service.

At this assessment, the rating has changed. This key question has been rated as 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.

At our last assessment in April 2022, the service had systems to learn and make improvements when things went wrong. However, these were not fully embedded.

During this assessment, we found the service had a positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. Representatives from the Patient Participation Group (PPG) felt the provider took concerns seriously and proactively made improvements to the service. Managers encouraged staff to raise concerns when things went wrong. During clinical meetings, the GPs, clinicians and practice manager discussed and learnt from clinical issues. Minutes of these meetings were shared with all staff.

Staff felt there was an open culture, and that safety was a priority. The provider had processes for staff to report incidents, near misses and safety events.

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.

There were systems for processing information relating to new patients. The service worked with other providers to deliver shared care and when patients moved between services.

Referrals were managed in a timely way. There was a system and process for monitoring and managing two week wait referrals (thetwo week waitreferral system allows a patient with symptoms that may indicate an underlying cancer to be seen as quickly as possible), which all staff knew and understood.

The service 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. The service shared concerns quickly and appropriately.

There were safeguarding policies known to staff, who were appropriately trained in safeguarding procedures. The service maintained a list of vulnerable people and acted on concerns working in partnership with other organisations. A review of safeguarding records showed alerts were appropriately placed on patients records and those of household family members when necessary.

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

Emergency equipment was available and maintained. Staff could recognise a deteriorating patient and knew what action to take.

Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

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

There were contracts to ensure the premises were maintained. Health and safety risk assessments and audits had been undertaken and risks identified had either been addressed or had an action plan with timescales for these to be completed.

The service 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.

There were a range of clinical and non-clinical roles within the service. Safe recruitment practices were followed. We found learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence. Staff told us of how they were supported to achieve career progression.

At our last assessment in April 2022, infection and prevention control processes were not fully embedded at the service.

During this assessment, we found the service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service had a designated infection, prevention and control (IPC) lead and all staff had had relevant training. There were cleaning schedules which were followed. Risk assessments and audits were completed. The IPC audit was effective and included an annual IPC statement.

At our last assessment in April 2022, the service did not have effective systems for the appropriate and safe use of medicines.

During this assessment, we found the service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning.

As part of our assessment a number of set clinical record searches were undertaken by a CQC GP specialist advisor. These searches were visible to the service. We found that patients who were prescribed high-risk medicines were monitored appropriately in most cases.

Staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely. This was accurately recorded in people’s consultation records. People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms.

There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.

Staff received regular training, were competency assessed on medicines optimisation (a person‑centred approach to safe and effective medicines use, to ensure people obtain the best possible outcomes from their medicines), and felt confident managing the storage, administration and recording of medicines.

Staff managed prescription stationery appropriately and securely. Staff followed protocols to ensure they prescribed all medicines safely, and ensured people received all recommended medicines reviews and monitoring.

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 in most cases.

Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics.