The Ivy Medical Group Also known as Lambley Lane 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

There was a proactive and positive culture of safety based on openness and honesty, in which concerns about safety were listened to, safety events were investigated and reported thoroughly in most cases, and lessons were learnt to identify and embed good practices. There were processes in place for managing emergencies and safety netting measures embedded in the triage system to manage clinical risk. Premises and equipment were managed safely with an overarching business continuity plan which had been recently tested for effectiveness. There were safe recruitment practices with a learning and development programme in place to support staff.

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.

We sought views of practice staff as part of this assessment which were sent to team via a questionnaire and returned directly to the CQC. We received 18 completed forms, all of which were treated confidentiality. The feedback was mostly positive from both clinical and non-clinical staff who spoke highly of the management and GPs, stating that they felt supported and that there was a strong focus on staff welfare. Staff confirmed they were aware of the incident reporting process and knew how to report concerns. They felt there was a no blame culture and they did not feel anxious about raising a concern with the management team or the lead GP who were always supportive.

We received concerns regarding the management of complaints at the practice. We found that the practice monitored and reviewed safety using information from a variety of sources including significant events and complaints. Staff told us they knew how to identify and report concerns, safety incidents and near misses. Learning from significant events and complaints were shared with staff and systems to identify trends in significant events and complaints were in place. Where changes had been implemented in response to learning, the effectiveness of the changes were reviewed. For example, a person had been referred to an external service, however, the person had omitted to update the practice with their new address; as a result, it is now the practice policy that addresses and contact details are checked when patients are referred. During the assessment we reviewed processes for learning at the practice and we saw evidence that both clinical and non-clinical members of the practice team were up to date with their mandatory training, and complaints and untoward events were discussed at team meetings to share learning and improve the services delivered for patients. We found that complaints were fully investigated, patients received a full response to their complaint, and learning was applied as appropriate. The practice received 46 complaints within a period of 12 months with the most common themes being about dissatisfaction with clinical consultation, care received and prescription/medication issues. Complaints were reviewed on a six- monthly basis. Anonymised details of the complaints were shared with the PPG and quantitative data regarding the reasons for the complaints were displayed in the waiting room. Compliments were also recorded and shared with the practice team, with 13 compliments recorded in the six months prior to our assessment.

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.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

Staff told us that they knew where to locate the emergency medical equipment and medicines in the event of an emergency. 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 contacted nursing and care homes, including a nursing home for people with learning disabilities, who had residents registered with The Ivy Medical Group for feedback on their collaboration with the practice. Their views were mostly positive regarding the care provided to their residents. They stated GPs were approachable and commended clinical care delivered by the Advanced Clinical Practitioner. They told us there had been an issue regarding issuance of prescriptions in a timely manner, and were told that a meeting would be arranged to discuss this, however, this meeting had not taken place at the time of our assessment.

We received concerns regarding processes for managing emergencies, emergency equipment, medicines and how the practice responded to patients who may be at immediate risk. We found that all members of the practice team had completed appropriate training, including life support training. There was a robust medical emergency procedure for the team to follow in the event of an emergency. During our on-site assessment we found that an adult and a child pulse oximeter for measuring the volume of oxygen in the blood had flat batteries, and one of two oxygen cylinders had expired the day before our assessment. The practice nurse immediately ordered a replacement oxygen cylinder to arrive the next day and the batteries were replaced. The practice agreed to review their processes for checking emergency medical treatment to include keeping pulse oximeters charged. However, additional informaiton provided by the practice following the assessment showed there was continuous availability of functioning equipment with additional units in stock in each consultation room at each practice site.

Leaders told us the business continuity plan had been recently tested and areas for improvement were identified from the test. Staff had no concerns about the environment in which they worked.

We checked mandatory risks assessments such as legionella, legionella water temperature checks, gas certification and electrical safety certifications which were satisfactory. Fire evacuation drills had been undertaken at both Lambley Lane and Apple Tree surgeries and there were trained fire wardens at both locations.

Health and safety risk assessments had been carried out and appropriate actions taken. The practice had a good business continuity plan covering fire, flood, loss of water, loss of electricity or gas, staff shortages and telephone and IT outages.

The practice had an extensive freedom to speak up policy which was available to all members of the practice team on the practice intranet. Staff told us that they knew who and how to contact the external speaking up guardian. Non-medical prescribers informed us that they felt supported and confirmed that they received structured and supportive supervision from the lead GP. The practice team told us that they felt supported by the leadership team and felt that their views were listened to. However, they felt that the practice would run more effectively with more administrative and clinical staff. Leaders told us whilst they valued staff feedback, staffing challenges were widespread across primary care and that staff feedback was reflective of this.

We saw staff employment files which showed recruitment checks were carried out in accordance with regulations (including for agency staff and locums). However, there were no risk assessments for cleaning staff who did not have Disclosure and Barring Service (DBS) certificates. The practice had an effective method to monitor training needs which was monitored by the assistant practice manager, and electronic notifications were automatically sent to the manager and employee when training was due to expire. The practice had an extensive clinical supervision policy detailing how non-medical prescribers were debriefed and supervised to ensure safe clinical practice. The advanced clinical practitioner provided support and supervision to the practice nursing team.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.