Salisbury Avenue Healthcare

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

During the assessment, we reviewed policies, spoke with staff, and undertook observations while on site. The practice had systems, processes, and practices to safeguard people. Staff had the information needed to deliver safe patient care and treatment. There were arrangements for reviewing and investigating safety and safeguarding incidents and events when things go wrong.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We spoke to two members of the practice’s patient participation group. Both parties said the provider did not share the details or outcomes of their complaints and incidents during the meetings.

Feedback from staff and leaders demonstrated that the practice had a culture of identifying incidents and complaints, learning, and improvement. Staff told us they could raise concerns and report when things went wrong.

The practice had a significant event and complaints policy and a reporting form that was accessible to all staff members. Incidents were discussed during team meetings, and the learning outcomes were shared with staff. The practice carried out an annual review of all complaints and incidents throughout the year to identify themes.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

All staff knew who the safeguarding lead was. Clinical staff regularly had discussions during clinical meetings; staff were aware of female genital mutilation (FGM) and trafficking requirements, and the practice used system searches to follow up with patients who did not attend appointments.

There were regular discussions between the practice and other health and social care professionals, such as health visitors, school nurses, community midwives and social workers, to support and protect adults and children at risk of significant harm. Partners told us about the extensive work they had carried out with the practice to improve their processes; they told us they had no concerns about the practice's safeguarding processes.

Safeguarding policies and procedures were available and accessible to all staff. There were regular discussions between the practice and other health and social care professionals to support and protect adults and children at risk of significant harm. We found safeguarding training was provided appropriately for all clinical staff.

During this assessment, we spoke to two patients. They told us they felt involved in their care and treatment.

Staff told us that patients were involved in their care and treatment.

The practice had multiple systems to support effective risk management. We saw that identified risks and lessons learned were discussed during clinical meetings, and the practice manager shared the meeting minutes with staff. Patients identified as at risk were involved in discussions and informed of options to minimise risks.

Staff knew who the lead staff members were, such as the infection control and safeguarding leads. Leaders informed us they regularly reviewed policies, and all staff had access to them. We reviewed the minutes of the practice's safeguarding meetings and saw that leaders shared information and safety concerns.

We observed the facilities and equipment as well-maintained and suitable for their intended use.

The practice had a range of risk assessments in place, including legionella and health and safety risk assessments. Medical equipment was calibrated, and portable appliance testing was undertaken to ensure it was fit for purpose and in good working order.

Patients told us they felt clinical staff were effective in their role and did not identify any concerns with staffing levels.

Leaders explained their recruitment processes to ensure appropriate numbers of suitably trained staff were employed to support the delivery of consistently safe, good-quality care that met the needs of the patient population. Staff told us they received the support needed to deliver safe care and could request additional training or support.

There were various policies related to the management of the practice to help maintain a safe and effective workforce. This included recruitment, appraisal, supervision, incident reporting, performance management and training. We checked six staff files; there were no concerns that the staff had completed role-specific training. Five staff whose files we checked had Disclosure and Barring Service (DBS) checks done. We saw clinical and practice meeting minutes. We saw that policies were reviewed and accessible to staff. We found that two non-clinical staff members had a DBS from their former employer. Two staff members did not have a full record of immunisations, and one of the staff members had a signed decline form. Neither staff had a risk assessment carried out by the practice. A few days following the inspection, the provider shared with us a newly completed risk assessment for both staff. Additionally, the provider revised their DBS policy to include a new DBS check for all new staff and risk assessments for staff who decline immunisations.

Patients told us the practice was always clean and well maintained.

Staff were able to confidently discuss their IPC responsibilities. They knew who the IPC lead was and how to report concerns. Leaders were able to discuss the processes to support effective IPC management.

The premises were visually clean, hygienic, and uncluttered. We reviewed the practice's cleaning logs, which showed regular cleaning.

Policies and procedures were available to staff, which provided guidance and information on infection prevention and control (IPC) practices. Staff had completed the infection prevention and control training relevant to their role and had all undergone sepsis training. The practice had acted on the issues identified in infection prevention and control audits. The provider had an IPC lead and waste management process. An in-house survey undertaken by the practice in June 2023 found their overall IPC compliance to be 98%.

The patients we spoke to told us they felt supported in understanding and managing any risks. Results from the practice’s patient survey in April showed that 100% of patients felt involved as much as they wanted to be in their care and treatment decisions.

Clinical staff described the practice's processes to ensure appropriate clinical oversight and told us how they monitored patients' health, including their use of high-risk medicines. We found that staff had good knowledge of current and relevant best practice and professional guidance.

During the on-site inspection, we found that the fridges were monitored and recorded daily. The staff knew what to do if the fridge temperature went out of range. Emergency medicines were securely stored, accessible, and monitored for use-by dates. Prescription stationery was removed from clinical rooms and stored in a locked cabinet, and their use was monitored.

The practice had a process for monitoring patients’ health using appropriate monitoring and clinical review before prescribing. The practice had a system for recording and acting on safety alerts. We carried out a remote review of the clinical record system and found the practice had taken appropriate action in response to safety alerts received. The practice was part of the North East London integrated care board, and monthly medicines safety newsletters were received, which shared learning from prescribing incidents. There was an effective system to evidence the competence of non-clinical medical prescribers, including clinical supervision. The practice had appropriate policies and procedures to govern prescribing effectively.

The remote clinical searches carried out by our GP specialist advisor indicated that patients' care and treatment were managed in line with current guidance and that information, including examination, management plans, safety netting, and follow-ups, was adequately documented. Patients prescribed medicines were monitored and reviewed in the required timescales, ensuring that all information needed was available for safe prescribing.