Wolverley 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 a total of 8 quality statements from this key question. We found safety was a top priority, and when concerns were raised the primary response was to learn and improve. The practice had effective systems in place to ensure patients were protected from abuse and harm.

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.

People were given the opportunity to provide feedback. There was information displayed in the waiting room and on the practice website advising patients on how to make a complaint. There was also a link on the practice website to the friends and family test where patients could leave anonymous feedback.

Leaders encouraged staff to raise concerns when things went wrong. Feedback from staff confirmed they understood and felt confident identifying and reporting concerns. Staff told us they felt there was an open culture, and that safety was a top priority.

The practice had processes in place 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. Significant events were standard agenda items at clinical and practice meetings and learning was discussed to improve care for others.

Patients were pleased about the prompt referral process and the practice worked with them to ensure continuity of care.

Staff had knowledge and understanding of local referral processes and arrangements. Reception staff had been trained to direct people to the most appropriate service.

We did not receive any concerns from commissioners or other system partners about safe systems, pathways and transitions.

Referrals to specialist services were documented, contained the required information and there was a system to monitor delays in referrals. There was a process in place to check all patients with 2 week wait referrals had been referred appropriately and received their appointment with a specialist. There was a documented approach to the management of test results, and this was managed in a timely manner. Our searches showed no concerns for the management of test results.

People told us they felt supported by the practice. We did not receive any concerns regarding safeguarding at this practice.

Staff were aware of their responsibility to safeguard patients from harm and knew how to raise a safeguarding concern. All staff had completed training to a level appropriate to their role and were aware of who the safeguarding lead was.

We did not receive any concerns from commissioners or other system partners about safeguarding systems and processes.

The practice had effective systems and processes in place to ensure patients were protected from abuse and harm. The practice had a safeguarding policy that was accessible to all staff. There were regular multidisciplinary team meetings between the practice and other health and social care professionals at which safeguarding was a standing agenda.

Patients’ needs were discussed during consultations and they were fully involved in their care and treatment.

Staff were aware of the importance of including people in decision making. Staff attended multidisciplinary team meetings where patients were discussed to help manage risks associated with them.

The practice held regular clinical and multidisciplinary team meetings to support effective risk management. Identified risks and lessons learnt were shared and discussed during these meetings.

Leaders and staff informed us of the effective arrangements to monitor the safety and upkeep of the premises. The practice manager had created a monthly hazard spotting checklist to help detect and control potential risks. All staff had completed fire, and health and safety training.

We observed the practice including facilities and equipment to be well-maintained, accessible and suitable for the intended purpose.

There were effective systems to ensure electrical equipment was regularly tested and medical equipment regularly calibrated. We saw evidence these had been completed annually. The practice completed regular risk assessments for fire, health and safety, legionella and Control of Substance Hazardous to Health (COSHH) and actions had been completed. The practice had maintenance records for checks of the fire alarm system, fire extinguishers and emergency lighting.

Patients were very satisfied with the service they received from staff. Patients were able to see the staff they wanted to when they booked an appointment.

Staff received effective support, supervision and development to deliver safe care. They had regular appraisals and were able to discuss their development. We saw evidence of staff being upskilled to support their development and the practice. Staff told us staffing levels were adequate to cover absences and busy periods.

We reviewed 3 personnel files during the site visit and found appropriate recruitment checks had been carried out. We reviewed the training records and found all staff had received appropriate training and were up to date with mandatory training.

Patients had no concerns about infection, prevention and control (IPC) when they visited the practice.

Training records showed all staff had completed appropriate training in infection prevention and control (IPC). This was in line with the practice’s policies.

We observed the practice to be visibly clean. Staff had access to appropriate personal protective equipment (PPE) and hand washing facilities in clinical rooms.

The practice had effective processes in place to manage IPC which included a policy that was easily accessible to all staff. They had an IPC lead, and we saw evidence of regular IPC audits being completed which included any resulting actions. The practice had arrangements in place to manage healthcare waste and staff were aware of the action to take in event of sharps or contamination injury. The practice had undertaken environmental risk assessments and had carried out recommended actions.

Results from the national GP patient survey showed that 83% of people said they had enough support from local services or organisations in the last 12 months to help manage their long-term conditions or illnesses. This was above both local and national averages. Patients received their medicines in a timely manner and felt the dispensary team were approachable and supportive.

The practice had protocols in place for staff to follow to ensure they dispensed medicines safely. Staff were supported by the GP’s and could readily contact a GP to answer queries. Staff felt confident managing the storage, administration and recording of medicines. Staff managed medicines-related stationery appropriately and securely.

The practice held appropriate emergency equipment and emergency medicine. Emergency equipment and medicines were checked regularly for expiry dates and stock levels. However, we found some stock that was out of date. The practice took immediate action and rectified this. Emergency medicines and equipment were readily available in an emergency.

The practice had a policy in place for the management of medicines including repeat prescribing. Staff had the appropriate authorisations to administer medicines (including Patient Group Directions (PGD) or Patient Specific Directions). We reviewed a sample of PGDs and found these had been appropriately signed by staff and authorised by a GP.

As part of our assessment, our CQC GP specialist advisor undertook clinical record searches. These searches were visible to the practice. We found that clinical monitoring at the practice was appropriate overall. The provider had effective systems to manage and respond to safety alerts and medicine recalls.