The Chesser Surgery

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• 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 assessed all quality statements from this key question. Our rating for this key question is good. We found that the service was providing safe services in most areas because there was an embedded learning culture with which all staff were familiar with. There were also clear patient pathways in place.

However, we found a breach of the regulations in relation to safe care and treatment. Staff reported to us that staffing levels were not sufficient. We also found that some staff had not received required training, and that not all staff had received an annual appraisal. The service appeared to be clean, but there were some areas in which infection control best practice was not being followed. Not all prescribed medicines were being monitored in line with national guidelines.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

All of the staff we spoke to were aware of how to raise incidents. Staff we spoke to detailed how learning was shared with them on both an individual basis, and organisation wide. Leaders detailed how they supported the process, and staff as required. However, although safeguarding training was mandatory, not all staff were aware of their safeguarding responsibilities and there was a risk that safeguarding concerns may not always be identified.

There was a system for recording and acting on significant events and incidents. There were adequate systems for reviewing and investigating when things went wrong. The service learned and shared lessons, identified themes and took action to improve safety in the service.

The service learned from external safety events and patient safety alerts. The service had an effective mechanism in place to review alerts and disseminate them to members of the team as required.

People did not raise any concerns regarding their experience of safe systems and processes.

The staff we spoke to were aware of care pathways, including referrals and taking on care of those patients who had been discharged from other services. Leaders at the service shared relevant information with staff in team meetings. However, not all staff were aware of their safeguarding responsibilities and there was a risk that concerns could be missed when people moved between services.

Partner agencies did not raise any concerns.

The service had processes in place to ensure that referrals and discharges were managed quickly. There were also systems in place to ensure that where care was shared, information was shared between organisations, for example where blood tests and monitoring were undertaken by another organisation.

Patients raised no concerns regarding their safety or safeguarding concerns.

Not all staff were aware of how to make a safeguarding referral or knew who the safeguarding lead was if they required further advice. Some staff were also unaware of their safeguarding responsibilities and were not able to detail what might constitute a safeguarding concern. Leaders told us how advice was available to staff as required.

There was no feedback of concern in relation to safeguarding from partner organisations.

The service worked with other agencies to support patients and protect them from neglect and abuse. There was a safeguarding lead for adults and children who took steps to protect patients from abuse, neglect, harassment, discrimination and breaches of their dignity and respect. However, the processes in place were not effective as not all staff were aware of their safeguarding responsibilities or knew who the safeguarding lead was.

The provider carried out staff checks at the time of recruitment and on an ongoing basis where appropriate. Disclosure and Barring Service (DBS) checks were undertaken where required. (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable).

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.

Staff at the service were aware of where all emergency equipment was stored. They also knew how to manage spillages if these occurred. Leaders at the service were able to detail the policies and procedures that were in place to ensure that the environment was safe.

We observed that the building in which the service was in place was fit for use. All equipment had been checked and calibrated as required. The service had a full range of emergency medicines and equipment (such as a defibrillator and oxygen) in place to ensure that emergencies could be safely managed. However, we found that the provider was not always compliant infection control protocols.

The service had undertaken a full range of risk assessments to ensure that the environment was safe, including premises, and health and safety. Where there was learning from these risk assessments, we saw that the service acted quickly to address any specific issues raised.

Patients raised no specific concerns regarding staffing levels.

Staff reported that in most areas there were sufficient staffing at the service. However, they reported that the level of administrative staffing had not been to complement and was currently insufficient. Leaders told us that they had worked hard to recruit to posts, and that there had been two new starters in the past several months. They told us they would continue to recruit until such time that staffing was at complement.

The service had a clear induction program. However, the service did not have adequate processes in place to monitor training undertaken by locum staff. We saw that one of the locums employed by the service did not have up-to-date training in infection control, information governance or fire safety.

Staff received 1:1 and team support from managers and received appraisals. All staff told us that they were appraised. However, staff reported that appraisal did not happen every year.

Chaperones, who observed intimate examinations as part of their role were provided with a standard DBS clearance only. Staff should have an enhanced DBS check to undertake this role.

We did not receive any specific concerns from patients regarding the cleanliness or hygiene of the practice.

Leaders told us that they had implemented cleaning schedules at the service, and regular monitoring of cleanliness was in place.

The service was clean and some of the clinical areas at the practice were fit for use. However, this was not consistent in all areas. Doctors’ rooms were carpeted, and the carpet was old and stained. In some areas the carpet was worn away and was being held together with tape. The floor and walls in GP consultation rooms did not have a curved join to assist cleaning and avoid a build-up of dust. The reception and waiting areas had older flooring, that had gaps filled with sealant. Both the floors and the sealant were discoloured, although they appeared to be clean.

Sharps boxes were not fixed to the walls of the service, and consequently there was a risk that they could be knocked over. The taps in some of the clinical rooms had a swan neck and were therefore not compliant with infection control/Legionella management guidelines. Managers and staff at the service reported they were currently looking into addressing these issues.

The service’s last infection control audit had identified areas that needed improvement. Some of these areas had been addressed, although others had not. There were systems for safely managing healthcare waste. The provider carried out appropriate environmental risk assessments, which took into account the profile of people using the service and those who may be accompanying them.

Leaders detailed the process by which the service used available searches on the clinical database to ensure that care being provided was in line with best practice.

The systems and arrangements for equipment, including medical gases and emergency medicines and equipment, minimised risks. The service kept prescription stationery securely and monitored its use, although the large majority of prescribing was completed electronically.

The practice had a system in place to monitor the fridge and clinical room temperatures for the safe storage of medicine, this was supported by a policy which had been recently reviewed. The practice had put systems in place to monitor the safe administration of patients’ medicines, the prescribing of repeat medicines and the monitoring of emergency medicines. However, the provider did not stock controlled medicines.

The service’s Patient Specific Directive process which allowed the Healthcare Assistant to provide injectable treatments and vaccinations was not in line with guidelines. The system did not include an identifiable physical or electronic signature from a named clinician specifying that such treatments could be provided. The provider explained that the service had been told that the system was not appropriate following an external review, and they were in the process of introducing a new system.

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 practice. We found that patients who were prescribed high-risk medicines were monitored appropriately in most cases. However, we found some exceptions. For example, in four of five records that we reviewed of patients who had been prescribed medicines to treat arthritis, the day or days of the week in which the medicine should be taken was not recorded. This is a requirement and ensures that patients receive the correct prescription.

We also noted that in the two records which we reviewed where medicines used to treat mood disorders had been prescribed, there was no documentation in the clinical record that the risks of the medication had been discussed with the patient, meaning it was unclear if informed consent was obtained before the medicine was prescribed. We also reviewed five records of patients who had received a medication review in the past three months. Two of these reviews had not been coded correctly on the EMIS patient record database.