Alrewas Surgery

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Medicines optimisation

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. There were systems in place to manage medicine optimisation.

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.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. Representatives from the Patient Group (PG) felt the provider took concerns seriously and proactively made improvements to the service. Leaders encouraged staff to raise concerns when things went wrong. 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.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. There were systems in place for continuity of care, including when people moved between different services. There was evidence that the provider reviewed these systems in the event of incidents and complaints. Minutes from the multidisciplinary community support team meetings showed that the practice worked with external health and social care providers. The provider worked with the health visiting service to ensure children and their families received appropriate support. A representative of a care home, where the practice provided care and treatment, told us the systems and care pathways between the home and the practice worked well. Staff told us that there was a documented approach to the management of test results and referrals, and this was managed in a timely manner. There were systems in place for processing information relating to new patients. The service worked with other providers to deliver shared care and when patients moved between services.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. There were named safeguarding leads with deputising arrangements and administration support systems in place. The providers electronic system identified patients and families with known safeguarding concerns. Safeguarding meetings were regularly held, and discussions took place around children and adults with emerging health care needs, these included the uptake of childhood immunisations. The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations.

The provider worked with people to understand and manage risks through a holistic approach. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. For example, to support patients with autism or neurodiversity, the practice offered separate, quieter rooms for use during appointments, appointments during less busy times and offers to adjust the environment by turning off the TV or reducing light levels to create a more calming atmosphere. The practice was equipped to respond to medical emergencies. Risk assessments had been completed to determine the range of emergency medicines held within the practice and a system to monitor medicine stock levels and expiry dates was in place. There was medical oxygen and a defibrillator on site and systems were in place to ensure these were regularly checked and fit for use. 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.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The building was all on one level, and was accessible for all, including those using mobility aids. There were disabled toilet facilities and baby changing facilities. There was a hearing loop available for those with hearing loss. The provider had health and safety and fire risk assessments in place to evaluate, address, and monitor any safety concerns related to the premises. We saw that action had been taken in response to risks identified, for example a fire risk assessment had highlighted a few areas that need addressing and we saw that the provider had addressed these. The provider had systems in place to test electrical equipment to ensure it was safe to use. There was a business continuity plan in place which was monitored and reviewed.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. Safe recruitment practices were followed. We reviewed the records of 5 recently recruited members of staff and found appropriate recruitment checks had been carried out, including Disclosure and Barring Service (DBS) checks and immunisation status. There were a range of clinical and non-clinical roles within the practice. Staff worked together well to provide safe care that met people’s individual needs. 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. The practice participated in a shared staff bank pool, with the Primary Care Network (PCN) to assist one another with workforce challenges.

There were systems in place for medicine optimisation to meet people’s needs, capacities and preferences. The provider had systems in place to manage and respond to safety alerts and medicine recalls. Leaders told us alerts on the electronic patient records were used to inform staff when patients were prescribed high risk medicines. Our clinical searches identified a lack of a coded documented record of risk advice provided to a number of patients regarding a specific medicine. Following this feedback during the onsite inspection the provider demonstrated they had implemented a plan to complete this action. Our clinical searches identified some patients had not attended their requested annual medication review despite regular reminders. The provider following this feedback put in place measures which included replacing repeat medicine to acute prescribing measures. The day of the week when patients should take a specific medicine requiring monitoring was absent. Measures were put in place by the provider following this feedback. Medicine reviews were carried out by GPs and pharmacists. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment. There were regular reviews of non-medical prescribing practice supported by clinical supervision and auditing of the effectiveness of staffs consultations and prescribing. Staff had the appropriate authorisations to administer medicines (including Patient Group Directions or Patient Specific Directions). Vaccines were appropriately stored and monitored in line with guidance to ensure they remained safe and effective. Blank prescriptions used in clinical rooms were kept securely, and their use was monitored in line with national guidance. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments