Pitsmoor 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

Safeguarding systems, processes and practices had been implemented. We observed the premises to be clean and tidy with appropriate safety risk assessments and audits in place. Appropriate infection, prevention and control (IPC) processes were in place and we saw actions were being taken to mitigate risks identified. Recruitment checks were carried out in accordance with regulations and the provider was in the process of recruiting to some clinical vacancies. Staff training was appropriate and up to date. The majority of staff had received an appraisal and there was a plan to address the 2 staff who were overdue. We observed clinical supervision was carried out informally. The provider told us they had a plan to formalise and document these sessions moving forward. Safe systems, pathways and transitions were in place. Referrals to specialist services were appropriate and monitored and there was a documented approach to the management of test results and hospital letters. Appropriate systems for the safe management of medicines including emergency medicines and equipment and medicines optimisation was in place. Although we identified some systems and processes that required review, action was taken immediately following the assessment to address these. For example, the process for monitoring patients on some high-risk medicines and the system to track blank prescriptions throughout the practice. There was a process in place to action national medicine alerts. Although we observed timely action had not been taken following a recent alert, the provider was aware of the alert and we saw evidence immediately following the assessment that this had been addressed. There was a positive learning culture in the practice. Staff knew how to identify and report concerns, safety incidents and near misses. The practice learned and made improvements when things went wrong.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Leaders encouraged staff to raise concerns when things went wrong. Staff understood their duty to raise concerns and report incidents and told us these were discussed in clinical meetings. Staff and leaders were able to share examples of incidents and complaints, learning and improvement.

The provider had processes for staff to report incidents and safety events. There was a system to record and investigate complaints. When things went wrong, staff apologised when appropriate and action was taken as a result to improve the quality of care for others.

We received no feedback from patients as part of this assessment regarding their experiences for this quality statement. We observed patient feedback regarding a delayed referral received prior to this assessment had been investigated as an incident to prevent the same thing happening again.

Staff who undertook referrals to secondary care understood the e-referral system and there were appropriate systems in place to prevent delays. Staff had a good understanding of local referral processes and arrangements.

We did not receive any concerns from commissioners or other system partners about delayed referrals or safe systems of care.

There were appropriate referral pathways in place to make sure that people’s needs were addressed. The provider dealt with incoming test results and clinical correspondence promptly. The service carried out regular multidisciplinary team (MDT) meetings to discuss patients who may be vulnerable and care records were updated to reflect any decisions made.

People taking part in the assessment did not provide any comments about safeguarding.

Staff told us they had received up to date training in safeguarding children and adults. They knew who the safeguarding lead in the practice was and how to raise concerns. Staff told us they attended regular safeguarding MDT meetings.

We did not speak with representatives from partner agencies as part of the assessment. However, the provider was able to demonstrate many examples of multidisciplinary and partnership working, for example, the health visitors attended the safeguarding meetings.

The practice had clear systems, practices and processes to keep people safe and safeguarded from abuse. There was a safeguarding policy in place which was accessible to all staff on the practice’s computer system and staff were trained to the appropriate level for their role. The practice held regular safeguarding MDT meetings. These were attended by the safeguarding lead, clinical staff and health visitors. Any actions discussed were recorded in individual patient records on their clinical system. The practice had a process in place to identify children who failed to attend secondary care and would contact them to discuss this. Looked after children and those on the safeguarding register had alerts on their records so staff could support them.

We received no specific feedback from patients regarding their experiences for this quality statement.

Staff were trained in basic life support and receptionists were aware of actions to take if they encountered a deteriorating or acutely unwell patient and they had received care navigation training. Staff we spoke with were aware of the location of the practice emergency medicines and equipment.

The practice had carried out a risk assessment of emergency equipment and held medicines to be used in the event of a medical emergency. We saw these were checked weekly in line with national guidance. Non prescribing staff had the appropriate authorisations to administer medicines. Patients residing in care homes had dedicated GP support. The practice held regular MDT meetings with external staff, for example, district nurses to support patients receiving end of life care. The practice held a weekly drop-in session with a social prescriber who could connect people to services to meet their practical, social and emotional needs which were affecting their health and wellbeing.

Staff told us they had the equipment they required to carry out their role and no health and safety issues were identified.

We found no concerns regarding the care environment, equipment or facilities at both sites during our site visit with the exception of the window blind in one clinical room which did not have security cleats in place to secure the blind cord as per national safety alert guidance. These were implemented immediately following the site visit and a risk assessment of both premises was carried out to check all rooms. The equipment we inspected had been appropriately checked and serviced to ensure it was safe to use. The practice was equipped to deal with medical emergencies.

The provider had appropriate health and safety policies in place. They carried out safety risk assessments and audits and we saw evidence actions were being taken to mitigate risks identified. The annual fire drill at the main site was overdue, however, we saw a date had been scheduled for this.

Although the majority of patients told us they were happy with their care and treatment they reported difficulty accessing the practice by telephone and to an appointment.

Half of the staff we received feedback from or spoke to told us they did not feel there were enough staff. Leaders told us that staff skill mix was reviewed regularly and they were in the process of recruiting to a vacant full time practice nurse post. A new salaried GP offering an additional 3 sessions per week was due to commence mid-November and an advert was due to go out imminently for a salaried GP for an additional 5 sessions per week. Staff told us they had received the training they required for their role and staff had received an annual appraisal with the exception of 2 staff. Managers told us there was a plan in place to address this.

The provider had processes in place to maintain a safe and effective workforce which included appropriate recruitment checks and staff training. The practice did not carry out formal clinical supervision sessions, however, we saw that these were carried out informally at weekly clinical staff meetings with external speakers attending to support with updates. The provider told us these sessions would be formally documented moving forward.

Staff confirmed they received training and updates on infection prevention and control (IPC) and the lead nurse for IPC had received specific training to carry out the role and was given time by leaders to do it.

We observed the practice to be clean and tidy on the day of our visit and we saw there were sufficient supplies of personal protective equipment available for staff with access to appropriate handwashing facilities. Appropriate cleaning equipment was available and clinical waste facilities were available to staff in all rooms we visited and waste awaiting collection was appropriately stored. However, the sharps bins in use in the rooms we visited were not signed. The IPC lead told us this would be reviewed.

Regular detailed infection, prevention and control audits were carried out and we saw actions were being taken to mitigate risks identified. The IPC lead monitored the action log and was able to request support from the Integrated Commissioning Board’s (ICB) infection control lead as required. Appropriate processes were in place for checking staff immunisation during recruitment.

Patients received regular reviews of their medication.

Staff and leaders told us they had systems and processes in place to support the safe prescribing of medicines. The practice employed a pharmacist and a pharmacy technician who supported the GPs in the practice. Prescribing and medicines management were discussed regularly at clinical meetings.

During our clinical searches we found structured medicine reviews were carried out and the majority of patients on high-risk medications were appropriately monitored. We identified some areas that required review, with 64 of the 273 patients on Gabapentoid medication (anti-epileptic agent commonly used to treat neuropathic pain) not having a record of a monitoring appointment in the previous 12 months. The provider took action to contact all these patients immediately following our clinical searches to arrange a review with the pharmacy team.

During our site visit we found medicines were stored securely throughout the main practice and branch site. The practice had completed a risk assessment of emergency equipment and these were checked weekly. Vaccines were ordered and stored in accordance with national guidelines and the practice had systems in place to monitor the temperature of vaccine fridges. Appropriate systems were in place to manage national medicines alerts. However, our clinical searches identified 241 of the 308 patients on a SGLT-2 (medicine used to treat heart failure, kidney disease and to reduce blood sugar levels) did not have a record that they had been advised of the potential risks associated with it as per a recent medicines alert (MHRA). We saw that the provider took action to contact these patients by letter immediately following our clinical searches. There was a system in place to monitor blank prescriptions with boxes being logged into the practice, however, the system to track their transit throughout the practice required review. Leaders forwarded evidence immediately following the site visit of an update to their process.

The practice had a policy in place for the management of medicines including repeat prescribing. The practice had systems in place for the safe and effective management of clinical correspondence that required changes to patients’ medication. Accurate and up-to-date information about peoples’ medicines was available, particularly when they moved between health and care settings. The practice had up-to-date Patient Group Directions (PGDs) in place for nurses carrying out specific vaccinations and healthcare assistant staff had a good understanding of Patient Specific Directions (PSD’s). All staff administering vaccinations were up to date with immunisation training.