Dudley Wood 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

At the last inspection, we found that the practice safeguarding processes were not embedded, there were gaps in staff immunisation status and no risk assessments had been completed to identify potential risks to patients or staff and the practice could not demonstrate that individual care records were managed appropriately, safe management of medicines needed strengthening. At this inspection we found significant improvements had been made. The practice had taken action to ensure there were safe systems and processes for learning, safeguarding, pathways and transition, health and safety, infection control, the environment, medicines optimisation and safe and effective staffing was in place and was being routinely reviewed and monitored. We found action had been taken to ensure people’s safety was integral to the care and treatment they received. All staff understood the importance of keeping people safe and where there were concerns identified about people’s safety these were actioned promptly, and improvements made.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Information reviewed demonstrated that people had opportunities to provide feedback and they knew how to make a complaint. Feedback and information were available in the practice and on their website. People told us they had enough time during their consultation, they felt involved in decisions about their care and treatment and had confidence and trust in the healthcare professional they saw or spoke to.

Staff and leaders understood their duty to raise concerns and report incidents and near misses. Staff were involved in investigating significant events and complaints and identifying learning. We saw evidence that any actions or lessons learned was discussed in practice meetings. Staff and leaders were able to share examples of incidents and complaints which had been investigated and staff told us they felt they were able to raise concerns and report when things went wrong. Feedback from staff and leaders demonstrated that the practice had a culture of identifying incidents and complaints, learning and improvement to continually identify and embed good practices.

The practice had a significant events policy and a reporting form which was accessible to all staff members. The practice had a significant events lead responsible for supporting staff in identifying and reporting significant events. The practice followed their significant events policy and discussed events and incidents during team meetings and learning was shared with staff. The practice had a duty of candour policy and involved people when managing significant events and errors. The practice had a clear system in place to record and investigate complaints. From the sample of complaint records we reviewed; we found the practice responded to people’s complaints in a timely manner. The practice offered apologies to people and lessons were learnt.

Information we reviewed during our inspection demonstrated that referrals were actioned in a timely way and were appropriate. We saw evidence of feedback from patients during our inspection who were satisfied in the care provided. For example, 91% of patients felt that their needs were met during their last appointment and 78% of patients felt involved in the care and treatment during their last appointment.

We found safe systems of care, in which safety was managed and monitored. For example, there was a system for processing information relating to new patients including the summarising of new patient notes and a documented approach to the management of test results. There were systems in place for referrals to appropriate services, which was managed in a timely way.

The provider told us that there were processes in place that was monitored and managed to keep people safe. For example, the provider was part of the primary care network and attended regular meetings with other agencies across the locality to share and discuss information relating to patient care and treatment. For example, those on the practice palliative care register and those requiring admission to secondary services or specialist care.

Leaders told us that clinicians made appropriate and timely referrals in line with protocols and up to date evidence-based guidance. This was supported by a system in place to ensure all patient information including documents, laboratory test results and referrals were reviewed and actioned in a timely manner. We found that test results were managed in a timely way and all workflow was followed up and actioned appropriately.

The practice had reviewed their policies for safeguarding and had strengthened this further. For example, they were able to demonstrate they had attended a recent serious case review and discussed safeguarding protocols at a practice meeting to review any future learning. In addition, to this they had re-engaged with other agencies such as the health visitor and school nurse to support and protect children at risk of significant harm.

There were policies and processes in place to keep people safe and safeguarded from abuse. The practice had a safeguarding lead for adults and children and all staff had completed safeguarding training to the required level for their role. The practice held a safeguarding register, and patient records we reviewed showed that they had been appropriately coded where safeguarding concerns had been identified. Clinical system alerts were used to identify patients who were at risk of harm or abuse. There were processes in place to follow up children and young people who were not brought to their appointments both at the practice and for secondary care appointments. Safeguarding meetings were held on a weekly basis to review patients at risk. In addition, the practice attended weekly multi-disciplinary meetings as part of the primary care network (PCN) to review vulnerable patients. There was a policy in place for the renewal of DBS checks. Records we examined showed that all staff had a DBS check in place or in the absence of a DBS there was a documented risk assessment to explain why a recent DBS was not 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.

The practice had a safeguarding lead for adults and children and policies in place to support staff in the event of a safeguarding concern. Staff we spoke knew of the policies and procedures available to support them and what to do if they had any concerns about a patient. We were told that the practice reviewed safeguarding in practice meetings and that children and young people who were not brought to their appointments were followed up. The practice held a safeguarding register, and clinical system alerts were used to identify patients who were at risk of harm or abuse. Staff were aware that these flags could indicate a potential risk.

Leaders told us that they worked with services locally to understand and manage risks. For example, there were regular primary care meetings held with other agencies so that care met patients needs and services were managed holistically. The practice also had registers in place to support those patients who were vulnerable or who had mobility or communication needs. All 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 had been given guidance on identifying such patients.

We found that processes had been strengthened to manage risks and these were being regularly reviewed. For example, there were registers to manage patients prescribed high risk medicines and for those that had a long term condition. These registers were regularly reviewed to ensure patients were followed up for appropriate monitoring. There were processes in place to ensure the practice prioritised care for their most clinically vulnerable patients and patients were told when they needed to seek further help and what to do if their condition deteriorated. There were systems in place to support patients who face communication barriers to access treatment (including those who might be digitally excluded).

Leaders told us that that health and safety, security and maintenance of the building was regularly reviewed to ensure this was to a safe standard. There was an appointed fire marshall and fire drill had been carried out in February 2024. All staff had completed health and safety training. This included basic life support and resuscitation training which had been completed in February 2024. Reception and administration staff who handled calls to the practice and arranged appointments with the clinical team were aware of potential red flag symptoms. Staff knew when to notify a GP or other clinicians with concerns about a patient who may be acutely unwell and/or deteriorating. Annual checks of the environment had been completed. This included an annual gas check, water and air checks, including checks for legionella which had been completed in May 2023. Portable appliance testing, calibration and fridge servicing had been completed in October 2023.

There were policies and procedures in place for the management of health and safety. Fire safety policies were in place and staff were aware of how to access these. Fire marshals had undertaken additional training for the role. Systems were in place for the regular checks of fire alarms, extinguishers and fire evacuation procedures. The practice had completed assessments in place for the control of hazardous substances. Evidence provided by the practice showed equipment was regularly calibrated and electrical items were PAT (portable appliance testing) tested.

During our site visit we found the premises were well maintained. There were a variety of processes in place to ensure the environment was safe. Infection control audits had been completed and actions identified had been acted on or were in the process of being completed. Fridge temperatures were recorded daily and a data logger was in place which was reviewed regularly to ensure the fridge temperatures were within a safety range. Risk assessments had been completed and staff were aware of processes if issues arose of how to act and the reporting processes.

There were policies and procedures in place for the safe recruitment of staff which had been reviewed further since our last inspection. The provider told us they had completed disclosure and barring checks for all staff working in the practice and that all newly employed staff had completed an induction to ensure they were competent in carrying out their role. There was clearly defined lead roles to support staff in carrying out their roles effectively and staff were supported by leaders. The practice had a programme of learning, which was monitored by the management team each month. We found that staff were up to date with training requirements, which included newly appointed staff. There were staffing rotas to ensure there were adequate cover in place. On speaking with staff, we were told there were enough staff on duty to cover busy periods and for staff absences. Reception and administration staff who handled calls to the practice and arranged appointments with the clinical team were aware of potential red flag symptoms. Staff knew when to notify a GP or other clinicians with concerns about a patient who may be acutely unwell and/or deteriorating.

There were processes in place for safe and effective staffing which had been reviewed since our last inspection. A recruitment policy was in place which included how the practice processed personal data in accordance with the General Data Protection Regulations (GDPR) and the policy outlined the requirements to obtaining a full employment history for prospective staff prior to employment. We reviewed 3 personnel files and found appropriate checks such as previous employment record, proof of identity and clinical staff files had evidence to demonstrate that clinical registration checks had been completed. Personnel folders were well organised and there was a systematic approach to ensure that personnel folders were managed appropriately. We found staff immunisation status records were in place. We found that processes had been reviewed for supervision and oversight and staff now had access to regular appraisals, clinical supervision and were supported to meet the requirements of professional revalidation. We found the practice had reviewed their processes and could demonstrate how they assured the competence of staff employed in advanced clinical practice, for example, nurses and physician associates.

The practice had policies in place for infection, prevention and control which was accessible to staff and Staff are aware of the action to take. For example, in the event of a sharps or contamination injury. There was an infection control lead in place and an infection control audit had been carried out in March 2024; the practice had achieved 96%. On reviewing the infection control action plan we found that actions had been completed. For example: staff training had been completed.

Leaders told us that they had taken action to address a number of areas for improvement from their last infection control audit. For example, they had employed a new cleaning contractor and addressed areas such as the decluttering of clinical rooms. All staff had completed infection prevention and control training and were aware of the systems and processes to follow to ensure clinical specimens were handled safely.

We observed the general environment to be clean and tidy and cleaning rotas were in place. Sharps bins were available in all clinical rooms which were signed, dated, safely sited and were not over-filled.

Emergency medicines, vaccines and medical equipment had been reviewed and were appropriately stored with clear monitoring processes in place. There were appropriate arrangements in place for the management of vaccines and for maintaining the cold chain. We saw fridge temperatures were routinely monitored and vaccines reviewed at random were in date and stored appropriately. The practice held appropriate emergency equipment and emergency medicines which were checked on a regular basis. Prescription paper was stored securely, and the practice maintained a record of prescription paper serial numbers. We looked at patient group directives (PGDs - a legal framework that allows some registered health professionals to supply and/or administer specified medicines to a pre-defined group of patients, without them having to see a prescriber (such as a doctor or nurse prescriber). We saw that they had been authorised appropriately.

Clinicians made appropriate and timely referrals in line with protocols and up to date evidence-based guidance. There was a system in place to ensure all patient information including documents, laboratory test results and cytology reports were reviewed and actioned in a timely manner. We found that test results were managed in a timely way and all workflow was followed up and actioned appropriately. Our review of patient records in relation to the clinical searches identified that care records were managed in line with guidance and legislation. The practice had systems for monitoring two week wait referrals to ensure patients were seen and held multidisciplinary meetings with other agencies to share and discuss information relating to patient care and treatment, for example, those on the practice palliative care register. We found that the practice had taken action to review safety alerts to ensure that these were being followed appropriately to ensure people were protected from harm.

Staff and leaders told us they had reviewed their systems and processes since the last inspection to support the safe prescribing of medicines. The practice worked with the clinical pharmacists from the local Primary Care Network and the lead GP reviewed their prescribing and management of patients receiving high risk medicines and medicines which require monitoring.

At the last inspection we found concerns in the management of high-risk medicines. However, during this assessment we carried out remote clinical searches and found that people who were prescribed high-risk medicines were monitored appropriately and action had been taken to ensure safe care and treatment was provided. Clinical searches of patient records were carried out as part of our inspection. A medicine (methotrexate) to treat rheumatoid arthritis which requires regular blood monitoring due to the risk of side effects, was looked at. It was found there were 15 patients who were prescribed this medicine and all had been fully monitored. We found there were 2 patients prescribed a medicine (azathioprine) to treat inflammatory conditions which require regular monitoring and found both patients had been fully monitored. A search was done for monitoring patients on a high-risk medicine, that is used to prevent strokes in patients with a fast heart rate. The medicines belong to a group abbreviated to DOACs. 2 of 56 patients on DOACs potentially showed as overdue renal blood test monitoring. We reviewed those patients and found appropriate action had been taken. A search on missed diagnoses of diabetes showed that 4 patients had been reviewed and followed up and long term conditions clinical searches showed care was generally good. There was clear processes for acting on safety alerts. We found that overall compliance to take action and review alerts were being taken.