Shakespeare Road PMS

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

At our previous assessment we rated the practice as requires improvement for the safe domain. We found that not all staff were trained at appropriate levels for their role, appropriate standards of cleanliness and hygiene had not been met and the practice’s systems for the appropriate and safe use of medicines were not always effective. At this assessment we found that staff were trained appropriately for their roles, infection prevention and control measures had been strengthened and were now robust. We found that the practice had improved their systems for the appropriate and safe use of medicines.

We found that the service had a good learning culture and people could raise concerns. Managers investigated incidents thoroughly. People were protected and kept safe. Staff understood and managed risks. The facilities and equipment met the needs of people, were clean and well-maintained and any risks mitigated. There were enough staff with the right skills, qualifications and experience. Managers made sure staff received training and regular appraisals to maintain high-quality care. Staff managed medicines well and involved people in planning any changes. There were systems in place to ensure that Medicines and Healthcare products Regulatory Agency (MHRA alerts) were followed. Patients on high-risk medicines were recalled for monitoring in a timely manner.

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 service had a proactive and 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. Staff we spoke with, told us they were confident raising significant events and could inform us of the process that would be undertaken. During staff meetings, the whole team discussed and learnt from clinical issues. Staff felt there was an open culture, and that safety was a top priority. The provider had processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Learning from incidents and complaints resulted in changes that improved care for others.

We saw examples of how some processes had changed following incidents that had been reported. An example of this, was how acutely unwell patients were managed when they required an ambulance. The GP who assessed and identified the requirement for an ambulance stayed with the patient to ensure an effective handover to the ambulance crew.

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, including when people moved between different services.

There were systems in place for processing information relating to new patients. The practice had a large contingent of patients registered who were new to this country. In a lot of these cases there was no medical history available for the patient. The practice offered “new patient appointments” to these patients, this was used to gather as much information as possible and then recorded on the practice’s clinical system.

The service worked with other providers to deliver shared care and when patients moved between services.

Staff understood their roles and had systems in place to manage tasks and test results, however, we found that this could be improved. We identified that some test results were not actioned within the required timeframe. The practice was a training practice for GP registrars, (doctors undergoing training to become a GP) test results were left by GPs so that they could be discussed with their GP registrar. Following our assessment this process was changed so that abnormal results were dealt with within the required timeframe and then discussed with the GP registrar at a suitable time.

At our previous assessment we found that the practice needed to improve how they managed Medicines and Healthcare products Regulatory Agency (MHRA alerts). At this assessment we found there were structured systems and processes in place to deal with MHRA alerts. These alerts are followed to ensure that medicines and medical devices are safe.

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.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations.

We found that all staff were appropriately trained in safeguarding procedures. There was a safeguarding lead for adults and children.

Chaperones were available, clinical and non-clinical staff had received training in this area. We saw posters on notice boards making patients aware they could request a chaperone should they wish.

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

Staff had received training in sepsis awareness and basic life support and were able to explain how to act safely in an emergency, including alerting clinical staff and the emergency services.

At our previous assessment we found issues relating to health and safety of the practice, including legionella risk assessments and how emergency medicine and equipment was managed. At this assessment the service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care and that risk assessments were continually reviewed and updated.

Contracts were in place to ensure the premises were maintained. The practice provided us with evidence of health and safety risk assessments and audits which had been undertaken and risks identified that had been addressed. We also saw there was a fire safety policy in place and regular checks were undertaken.

There was a business continuity plan in place which was monitored and reviewed. We saw that all staff had completed mandatory training in fire safety. Emergency medicine and equipment was stored and managed appropriately.

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. Managers made sure staff received training and regular appraisals to maintain high-quality care.

There were a range of clinical and non-clinical roles within the practice. We found training was up to date, learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence. Safe recruitment practices were followed. As part of this assessment, we looked at recruitment files of 2 members of staff, this included 1 administrative role and 1 in a clinical role. All files had appropriate checks carried out.

At our previous assessment we identified that there was not a formalised process to ensure that non-medical prescribers had their competencies assessed and monitored in-line with national guidelines. At this assessment we found a formal documented approach was in place, this included random checks that were carried out to ensure staff were working to the appropriate competencies.

At our previous assessment we found that processes and systems for dealing with infection prevention and control required strengthening. We found that not all areas of the practice, in particular handwashing sinks and toilets, were cleaned adequately or effectively. At this assessment we found that handwashing facilities had been upgraded, we observed the practice to be clean and tidy throughout.

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 practice had a designated infection, prevention and control lead and all staff had had relevant training. Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks. As part of our visit, we reviewed treatment rooms, consultation rooms and stockrooms at both sites.

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.

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

Staff received regular training, were competency assessed on medicines optimisation, and felt confident managing the storage, administration and recording of medicines.

At our previous assessment we found that prescriptions were not managed securely. At this assessment, 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. Searches we ran on the practice’s clinical system identified potentially 17 patients on disease-modifying anti-rheumatic drugs (DMARDs) that had not received the required monitoring within the last 6 months. We looked in detail at 5 patients and found 3 of the 5 patients had been reviewed appropriately. One patient had not had the required monitoring though the practice had contacted them numerous times. The other patient had not been swapped to a different medicine which had been highlighted in a hospital letter. Both patients were immediately reviewed by the practice. Patients on direct oral anticoagulant medicine (DOACs) were all being reviewed and monitored correctly.

Searches identified 6 patients from 15 with heart failure who were prescribed an aldosterone antagonist (medicine used to treat high blood pressure and heart failure) who had potentially not received the required monitoring. We looked in detail at these 5 patients and found that, there were issues with 2 of the 5 patients. Both patients were over a month out of date for having the required monitoring. This was immediately addressed by the practice when it was fed back to them, and a system was put in place to prevent this from happening again. The other 3 patients were very minimally overdue monitoring.

Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines which were stored on site.

The provider had effective systems to manage and respond to safety alerts and medicine recalls. We found that there were systems and processes in place to regularly review these. At our previous assessment we found that these arrangements had not been in place.

There was a programme of regular clinical audits of prescribing that focused on improving care and treatment. This included audits on diabetes compliance, a vitamin D audit and an audit on pregnancy prevention plan.