Holmcroft 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

This is the first inspection for this service since its registration with CQC. We found there were systems in place for significant events, patients’ complaints, and national safety alerts. However, we noted they had not ensured verbal complaints were included in trend analysis and for early identification and mitigation of risk. The practice worked as part of a multi-disciplinary team to support vulnerable adults and children and processes for the management of safeguarding concerns were in place. Appropriate systems were in place for the management of emergency medicines and equipment. Health and safety risk assessments had been completed to mitigate potential risks within the practice. Referrals to specialist services were appropriate and there was a documented approach to the management of test results. An infection prevention and control (IPC) lead was in place and IPC audits had been completed. There were systems and processes for the monitoring and prescribing of medicines that require monitoring. However, our clinical searches identified areas for strengthening. We also found the staff skills matrix developed to identify which clinical staff could treat or provide care for specific medical conditions required further clarity. The proposals suggested for clinical staff competency assurance needed to be implemented and embedded. This key question has been rated as good.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Lessons were learnt but these were not always well documented in order to continually identify and embed good practice. The provider had processes for staff to report incidents, near misses and safety events. Staff and the leadership team understood the processes in place. There was a system to record and investigate complaints. When things went wrong, staff apologised and gave people support. Learning from complaints resulted in changes that improved care for other people. Verbal complaints were noted in a book held in reception and actioned. The information from the book was not always used in conjunction with the written formal complaints, which could have led to missed opportunities for trend analysis and early identification and mitigation of risks. We sampled 3 significant events; they lacked clear documentation on the learning outcome improvement(s) made and embedded. During our onsite visit, the practice located the evidence to demonstrate the learning and cascade of improvements made in 2 of the 3 events we sampled. Leaders considered how improvements could be made to ensure that the learning and evaluation of the mitigating actions taken were auditable. Representatives from the Patient Participation Group (PPG) found in the last few months the leadership team had taken their concerns seriously. They had engaged and worked with them and the Holmcroft working group patients to find solutions and make improvements to the service. For example, a learning event had been hosted at the local library on digital patient access with further engagement with patients planned. Leaders encouraged staff to raise concerns when things went wrong. During various staff meeting forums, the team discussed and learnt from clinical issues. Staff told us that as a relatively new team, they had developed an open culture, supported by the manager on site, and that safety was a top priority

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.

The practice had systems in place for processing information in relation to new patients. There was a policy and procedure in place for all patients referred under a 14-day wait and to monitor the referral's progress. A process had been implemented in relation to managing test results. The service worked with other providers to deliver shared care and when patients moved between services. However, they had experienced difficulties in securing these agreements with secondary care. Of the 206 people identified there remained 73 people where these agreements were a challenge to obtain. This was escalated to the relevant organisations.

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 which was reviewed in a timely way and acted on concerns working in partnership with other organisations. Information was available in clinical rooms regarding the safeguarding process, should staff need to access it quickly.

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. People using the service 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.

Contracts were in place to ensure the premises were maintained. Health and safety risk assessments and audits had been undertaken and risks identified had been addressed. There was a business continuity plan in place which was monitored and reviewed.

The service 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 practice had a variety of clinical and non-clinical roles. We found training was up to date and the development of staff was managed appropriately. A skills matrix had been developed for clinical staff to demonstrate which clinician could treat specific medical conditions; however, this was not always clear. We fed this back to the practice who stated they would strengthen the matrix to make it clearer. Staff received effective support; however, we identified although staff were noted as having been in receipt of clinical supervision, there was no sampling of patient consultation records, or prescribing, for the provider to be assured of staff's competence. Leaders told us they were aware of this, and plans were in place for this to commence soon. However, the systems proposed had yet to be implemented and embedded. Safe recruitment practices were followed.

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.

Infection prevention and control policies were in place and followed by staff. The practice had a designated infection, prevention and control lead and staff had received relevant training. Cleaning schedules were in place and followed, which we saw documented. Risk assessments and audits were completed, and actions taken to mitigate risks. For example, the practice had installed CCTV cameras to an outside area where there had been concerns that items were being disposed of incorrectly by the public.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities, and preferences. They did not always involve people in planning.

Protocols were in place to manage and respond to safety alerts. However, our clinical searches found 12 out of 40 people had not received recent blood pressure checks for a medicine that did require these checks. We sampled 5 of the 12 records. All 5 had not had a recent blood pressure check or been informed of the risks of this medicine. Although there was a programme of regular clinical audits this highlighted a gap in the process. Medicines were stored securely and at appropriate temperatures. Staff checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines. Staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely. Staff received regular training, and felt confident managing the storage, administration and recording of medicines. There were systems in place for staff to manage prescription stationery appropriately and securely. Staff stored medical gases, such as oxygen, safely and completed safety risk assessments.