The Acorn & Gaumont House 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

We assessed all quality statements from this key question. At our previous rated inspection in March 2022, the practice was rated inadequate at providing a safe service because they were unable to demonstrate that safe systems or practices were in place or working effectively in relation to the child safeguarding register and management of medicines and emergency equipment. We also found a breach of the regulations in relation to safe care and treatment. During this assessment we found that the service was providing safe services in most areas. The service had an embedded learning culture with which all staff were familiar. There were also clear patient pathways in place. The service had clear safeguarding processes and staff had received safeguarding training that was relevant to their role. However, we found a breach of the regulations in relation to medicines optimisation. This was because not all prescribed medicines were being monitored in line with national guidelines.

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.

We did not receive any negative feedback from patients regarding the practice's culture to learn and improve from events.

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.

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.

Patients did not raise any concerns regarding safe systems of care operated by the practice.

The staff we spoke to were all 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.

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.

We received no specific feedback in this area.

Staff at the service to whom we spoke were aware of how to make safeguarding referrals and knew the identity of the practice safeguarding leads if further advice was needed. Leaders told us how advice was available to staff as required.

The service worked with other agencies to support patients and protect them from neglect and abuse. Staff took steps to protect patients from abuse, neglect, harassment, discrimination and breaches of their dignity and respect. 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). All staff received up-to-date safeguarding and safety training appropriate to their role. They knew how to identify and report concerns.

We received no specific feedback in this area.

Leaders told us that staff were informed in managing risk, and that standing items such as safeguarding and incidents were discussed at all meetings. Staff reported that they were included in risk management, and that they were happy to report when things went wrong.

There were process in place for risks to be discussed with all staff. However, the service did not have a formal mechanism by which risks were reviewed, managed and mitigated. Although we found no evidence of a negative impact on patients, without a formal process in place the provider had no means of ensuring that the process was being effectively implemented.

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.

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.

We received no specific feedback in this area.

Staff reported that in general there were sufficient staffing at the service, but that at times an increase in numbers might be beneficial. Leaders told us that they had worked hard to recruit to posts.

The service had a clear induction program. We spoke to new starters at the service since the last inspection, and they told us that the induction had been helpful. Staff also received 1:1 and team support from managers and received appraisals.

The national patient survey does not specifically query satisfaction with regards to infection control. We did not interview individual staff during the assessment.

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 all of the clinical areas at the practice were fit for use. Curtains were changed regularly, and sharps and other clinical waste management was managed appropriately.

The provider ensured that facilities and equipment were safe and that equipment was maintained according to manufacturers’ instructions. 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.

We received no specific feedback in this area.

We spoke with the clinical leads and nursing staff and found they were aware of their roles and responsibilities surrounding medicines management. For example, a weekly meeting was held to discuss medicines management and updates regarding safety or medicines alerts were shared with clinical staff via email.

Staff managed medicines safely and regularly checked the stock levels and expiry dates for all medicines, including emergency medicines, vaccines, and controlled drugs. Staff regularly checked equipment used in medical emergencies such as oxygen and defibrillators to ensure they were safe and in date.

Staff had the appropriate authorisations to administer medicines including Patient Group Directions or Patient Specific Directions (written instructions to help you supply or administer medicines to patients). Audits were used to ensure that medicines were prescribed appropriately and identify areas for improvement. Medicines reconciliation (the process of accurately listing a person’s current medicines) was completed for patients discharged from hospital. The provider had effective systems to manage and respond to safety alerts and medicine recalls. However, the provider did not have effective systems in place to monitor patients who had been prescribed high risk medicines.

Data reviewed as part of our assessment showed that the provider was prescribing medicines safely in most cases. However, we noted that not all prescribed medicines were being monitored in line with national guidelines. We reviewed clinical records for patients who had been prescribed medicines which required routine monitoring. This included patients who had been prescribed lithium (a medicine used to treat mood disorders) and DMARDS (a disease modifying anti-rheumatic drug). Our review found 2 patients prescribed lithium and 2 patients prescribed DMARDs had not been monitored and reviewed in line with current clinical guidelines. The provider has since taken steps to address these omissions. We also found that one patient with a specific condition had test results out of the normal range, but the test had not been repeated.