• Doctor
  • GP practice

Abbeywell Surgery Also known as Abbey Mead Surgery, Romsey

Overall: Good read more about inspection ratings

The Abbey, Romsey, Hampshire, SO51 8EN (01794) 512218

Provided and run by:
Abbeywell Surgery

Report from 12 February 2024 assessment

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Safe

Good

Updated 11 July 2024

The safe key question has been rated good. Staff promoted a culture of collaborative working with safety central to decisions. Safety was a priority for staff and leaders. Where people raised concerns about safety and ideas to improve, the primary response was to learn and improve continuously. There was awareness of the areas which demonstrated safety risks. Solutions to risks were developed collaboratively. Services were planned and organised with people and communities in a way that improved their safety across their care journeys. People were supported to make choices that balanced risks of harm with positive choices about their lives. Leaders ensured there were enough skilled people to deliver safe care that promoted choice, control and individual wellbeing.

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.

Learning culture

Score: 3

We found 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. Lessons were learned to continually identify and embed good practices. The practice learned and made improvements when things went wrong. Staff knew how to identify and report concerns, safety incidents and near misses. There was evidence of learning and dissemination of learning. The practice held a series of regular meetings for all staff both clinical and admin. Minutes were available for those unable to attend. Feedback we received from staff was positive about the learning culture in the practice.

The practice had systems and processes in place to manage safety events. They demonstrated how they investigated, identified learning and any improvements that were required. We saw the practice recorded events to ensure they were managed in a timely way. We reviewed some ways the practice shared learning with staff such as team meetings, where minutes of meetings were taken which demonstrated a formal approach to managing learning. Staff confirmed they had attended meetings and had access to the minutes.

Safe systems, pathways and transitions

Score: 3

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.

Safeguarding

Score: 3

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

Involving people to manage risks

Score: 3

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.

Safe environments

Score: 3

The practice worked with people and partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. They ensured continuity of care, including when people move between different services. Staff had the information they needed to deliver safe care and treatment. Individual care records, including clinical data, were written and managed securely and in line with current guidance and relevant legislation.

We reviewed systems for sharing information with staff and other agencies staff used this information to enable them to deliver safe care and treatment. Referrals to specialist services were documented, contained the required information and there was a system to monitor delays in referrals.

There was a documented approach to the management of test results, and this was handled in a timely manner.

Safe and effective staffing

Score: 3

The leaders told us about recruitment processes to ensure the right staff were employed in terms of skill mix to make sure people were receiving good quality care to meet their needs. The staff we spoke with told us they had adequate time to complete training, they told us they could raise with leaders any additional training or support required to meet their needs. Leaders told us policies in place where staff can learn from missed opportunities and poor performance was managed appropriately.

Throughout the inspection the practice evidenced a variety of polices to help them maintain a safe and effective workforce which included, recruitment, supervision, incident, performance management and training. Oversight of staff training was effective, and we saw online records that demonstrated when training was due and completed.

Infection prevention and control

Score: 3

There was an infection control lead in place and infection control audits had been carried out at both sites in January and February 2024. On reviewing the infection control action plan we found that actions had been completed. For example, areas of concern were addressed with the cleaning contractors.

We observed the general environment to be clean and tidy and cleaning rotas were in place. Sharps bins were available in all clinical rooms and were maintained in line with guidance.

The practice had policies in place for infection, prevention and control which was accessible to staff and staff are aware of the action to take. For example, in the event of a sharps or contamination injury. All staff had completed infection prevention and control training and were aware of the systems and processes to follow to ensure clinical specimens were handled safely.

Medicines optimisation

Score: 3

Staff were trained and their prescribing behaviours were monitored and overseen by the medicine management lead. Best practice was shared during clinical meetings with staff and regular audits were conducted to check standards of care.

Staff utilised clinical templates to conduct consistent assessments and assist them in identifying and responding to individual’s needs. Staff prescribed, administered and monitored people on who had been prescribed medicines.

There were systems in place to support staff to prescribe medicines safely. Prescribing templates were used by staff to assess, review and support prescribing. The practice had an appointed medicines management lead who conducted audits on their prescribing behaviours. The medicine management lead conducted regular system wide checks on prescribing. Where anomalies were identified with individual clinical practice these were raised with the prescribers, investigated and actions taken to safeguard the patient such as scheduling a review of their care and arranging monitoring (blood tests, blood pressure checks, recording height and weight). There were establish shared care agreements in place (to coordinate patient treatment with other healthcare professionals).