Kingsway 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

The practice mostly delivered safe care and treatment to patients. There were enough staff to deliver safe care and treatment. Staff understood how to report incidents, and managers shared results of investigations with staff to improve care. Medicines were stored safely in line with best practice guidelines. However, not all patients who needed regular reviews of their medicines received these. We highlighted this to leaders at the service who took action to identify patients who required reviews and ensured these were completed.

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.

The evidence we reviewed did not show any concerns about people’s experience regarding the learning culture.

Staff interviews demonstrated there were clear governance arrangements to deliver high quality care and treatment, tailored to the needs of the local population. Staff were aware of their responsibilities and knew how to identify and report concerns and incidents. Leaders shared learning with staff during team meetings.

Staff had access to up to date policies and procedures to support them to report incidents. When incidents were reported, leaders investigated these and shared outcomes and learning with the wider staff team to make sure care and treatment was improved. Learning from incidents was shared during team meetings. Where staff could not attend these, leaders shared minutes to make sure all staff were aware of any updates about patient safety.

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.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

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

The evidence we reviewed did not show any concerns about people’s experience. Patients felt safe regrading their care and treatment and staff felt confident in their roles and responsibilities.

The service had sufficient numbers of trained and competent staff to safely support patients without using agency nurses or locum doctors. Staff told us they had time to speak to patients and listen to patients' concerns. Staff received an induction when they started at the practice, and ongoing mandatory training however some staff were out of date with their mandatory training. We raised this with leaders who addressed this during the assessment period. Staff told us they felt confident to approach managers if they required support with training or continued professional development. Managers were aware of upcoming staffing levels and therefore could organise cover internally where necessary to meet demand.

At the time of the inspection, the practice did not have a system in place for auditing the non-medical prescribers. However, since the inspection, a bi-annual audit has been developed and the findings of the first audit show the patient’s care and treatment plans are being delivered in line with clinical guidance. Not all processes were effective to monitor staff training and competencies. The service had a training matrix which outlined which staff had completed mandatory training; however this was not sufficiently reviewed as we found some staff were out of date. However, during our assessment this was reviewed and managers provided assurance that this process was more robust. We also found that there was no system in place to audit the non-medical prescribers to check their competency in prescribing medicines.

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.

The evidence we reviewed did not show any concerns about people’s experience regarding medicine optimisation.

Staff told us patients were involved in decisions about their medicines during reviews and assessments. We found that staff had good knowledge of current and relevant best practice and professional guidance. Staff highlighted that medicines were stored safely and securely with access restricted to authorised staff. Staff were able to demonstrate the monitoring of emergency medicine stock levels and expiry dates. There was medical oxygen and a defibrillator on site and systems to ensure these were also regularly checked and fit for use.

The processes in place to review patients who were prescribed medicines which required regular monitoring were not effective. We found patients who were overdue for their medicine’s reviews. For example, patients on ACE inhibitors were all overdue monitoring. The provider was responsive to our findings and took action immediately, provided further detail from secondary care, contacted patients for review and held a clinical meeting to discuss findings and re-emphasised the importance of following policy.

Searches of the patient clinical system were made to ensure patient care and monitoring was completed in line with current guidelines. During our assessment, we conducted remote clinical searches which allowed us to review patients medical records to understand the practice's patient population, and to ensure they were receiving safe and effective care. We highlighted patients to the practice that we deemed at potential risk, to which the practice were responsive and provided evidence of follow ups and actions taken. Although we did not find any current impact on patients, there was a risk of conditions not being well managed because full oversight was not embedded.