Nutgrove Villa 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 3 quality statements from the Safe key question at this focused assessment. We have combined the scores for these areas with scores based on the rating from the last inspection, which was Good. Our overall rating for this key question is Good.

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.

During the assessment we spoke with a member of the practice Patient Participation Group (PPG) who was also a patient at the practice. We were told that patients were encouraged to make informal or formal complaints when their experience was poor. Staff were willing to listen to individual patients and the PPG when suggestions were made for improvements. We heard how patients’ views about medicines and prescription concerns were discussed at PPG meetings, so that solutions to the problems could be discussed.

Staff told us they were encouraged and supported to raise concerns. They felt confident that they will be treated with compassion and understanding, and won’t be blamed, or treated negatively if they do so. Staff told us that systems were in place to support people who wanted to make a complaint about their care and treatment. They were aware what they should do in these circumstances and how best to support patients with this.

The practice had effective processes and monitoring in place for reviewing safe care and treatment. These included reviewing national safety alerts, managing incidents and significant events. However, for more complex incidents, the records and details of events, did not always include evidence of robust in-depth analysis of incidents. The provider had a complaints policy and procedures, and these were in line with recognised guidance. The practice learned lessons from individual concerns and complaints and from analysis of trends. They had processes and systems to ensure compliance with the requirements of the duty of candour. The practice had a Patient Participation Group and regular meetings took place to gain patient views about their experiences. They monitored patient feedback as part of their complaints process and when reviews were made on the internet. The practice encouraged patients to complete the NHS Friends and Family test (FFT). The FFT is an opportunity for patients to provide feedback on the services that provide their care and treatment.

During the assessment we spoke with a member of the practice Patient Participation Group (PPG) who was also a patient at the practice. They confirmed they knew which clinicians were working each day so they could book appointments for continuity if they wished. Experiences of referrals to hospitals and other services had been positive for patients.

Feedback from staff and the management team was that safety and continuity of care was important throughout people’s care and experiences. This included patient referrals, admissions and discharge, and where people were moving between services. A number of examples were discussed related to this such as, end of life experiences for people and the care provided as older patients transitioned into a care home setting.

There was a system for processing information relating to new patients, including the summarising of new patient notes. There was a standard operating procedure (SOP) for managing incoming correspondence into the patient’s medical records. Correspondence Workflow Processes (CWP) were in place to ensure patient correspondence was managed appropriately by the right clinical and non-clinical staff. Policies were in place for pathology and blood test results management, ensuring all results were viewed by the clinical team. Processes were in place to ensure referrals to specialist services were documented, contained the required information, and were appropriately monitored. Logs and spreadsheets were in place to monitor that referrals had been accepted, patients had attended as requested and the outcomes of the referral were communicated back to the practice. This included routine and more urgent patient referrals. Following the assessment, the practice confirmed they had also commenced a log for all hospital admissions and urgent referrals outside of the two week wait criteria for referrals. There were systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment, for example with out of hours providers. Meetings took place with partners to ensure effective monitoring of care continued as people moved between services. For example, monthly Gold Standard Framework (GSF) meetings took place with community partners to monitor the needs of patients on the end-of-life pathway. Records of these meetings showed this enabled the practice to be aware of the risks to patients and families, as they potentially moved between services or as they progressed along the pathway.

We were unable to speak to people directly about safeguarding for this focused assessment.

Staff we spoke with were aware of how to identify, report and take action for safeguarding matters or concerns. The practice had a designated lead for safeguarding adults at risk and staff were aware of this.

We did not speak to partners directly about safeguarding matters for this focused assessment.

Safeguarding systems, processes and practices were developed, implemented and communicated to staff. Policies and procedures had recently been updated at the time of assessment. New policies included up to date information for contacts and were aligned with other local safeguarding teams. The practice had a register for vulnerable adults and children, however, we found this had not been reviewed and updated. The practice worked with other agencies to support patients and protect them from neglect and abuse. For example, multi-agency meetings were held when safeguarding investigations took place and there were lessons to be learnt. The Out of Hours service was also informed of relevant safeguarding information. While safeguarding matters were discussed at staff meetings, there were no meetings with local partners, such as health visiting teams, to discuss vulnerable children. Immediately following the assessment, the practice manager confirmed that work had begun on the verification of the register and dates for safeguarding meetings were set up. Partners and staff were trained to appropriate levels for their role. However, at the time of assessment some of this training had recently lapsed. Immediate actions were taken by the provider, and we received confirmation that all staff had updated their training. The practice had a chaperone policy in place to maintain patient privacy during intimate examinations. Posters were displayed in all consultation rooms and waiting areas.

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.

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

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.