Severn 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 had effective systems to assess, monitor and continue to improve the quality and safety of service. There were processes for monitoring patients’ health in relation to the use of medicines including medicines that require regular reviews. There were processes in place to monitor staff training including locum GPs, however, during the assessment we had to seek assurances that the provider could evidence appropriate safeguarding training had been undertaken by locum GPs. We also found fire safety training had expired. However, the practice started to action risks identified during the assessment process.

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.

Patient feedback regarding learning culture was limited. However, information we did receive was positive stating they felt listened to when raising concerns and changes were made when appropriate.

Staff told us of an open and honest working environment where they felt supported and able to raise concerns, this aided the learning and development of the staff and service provided.

Leaders evidenced systems and processes in place to raise concerns alongside methods of sharing outcomes from investigations to the wider team. These learning events were discussed weekly and quarterly at meetings held. Staff who were absent would receive meeting minutes to ensure they were made aware of learning and changes made.

The evidence we reviewed did not show any concerns about people’s experience regarding safe systems, pathways and transitions at this practice.

Staff told us about signposting and workflow regarding external services and the use of referrals. We found staff were knowledgeable in their role and were aware of support networks in the local area.

Practice partners described how care was delivered and reviewed. They told us how care was coordinated when different teams, services or organisations were involved.

There were systems and processes to share information with staff and other agencies to enable them to deliver safe care and treatment. This included regular multidisciplinary meetings between the practice and other health and social care professionals such as health visitors, community midwives and social workers.

The evidence we reviewed did not show any concerns about people’s experience regarding safeguarding at this practice.

Staff told us about how they would raise safeguarding concerns, we found they had a clear understanding of safeguarding with the appropriate training in place. Staff were aware of the safeguarding lead and evidenced literature around the practice to signpost them to support.

Partners told us about regular meetings that were held within the practice where safeguarding was discussed. The partners were able to demonstrate a clear understanding evidenced by policies and processes to ensure that necessary care was taken.

During our assessment we found that the provider had systems and processes in place to ensure patients were safeguarded from harm. We gained remote access to patient records and found no risk associated with patients on the safeguarding register. However, at the time of reviewing staff training it wasn't clear the assurances the practice had to ensure locum safeguarding was obtained. The practice were able to provide assurance during the inspection and evidenced ways they obtained locum information through an induction and could evidence safeguarding training for locums used.

The evidence we reviewed did not show any concerns about people’s experience regarding involving people to manage risks at this practice.

Staff told us that people are informed about any risks and how to keep themselves safe through their treatment of conditions. Leaders told us of ways that they regularly review consultations to ensure risks were managed whilst respecting patient choice.

The practice discuss cases in meetings to share risk and lessons learned, the practice also undertakes quality improvement audits which allows them to review work done, risk and involve patients in care.

Staff told us they felt safe to work at the practice, they told us facilities, equipment and technology are well-maintained so they can work safely and deliver a good quality of care to their patients.

We found no concerns regarding the location or the equipment within, risk assessments were completed and the practice met the population needs.

The practice had a risk log which they reviewed regularly to ensure risk assessments and actions from the assessments were completed. The practice had systems in place to report new and emerging risks should they occur.

Feedback we received from Give Feedback of Care stated there were enough staff to meet the needs of the patient population.

The leaders told us about recruitment processes to ensure the right staff are employed in terms of skill mix to make sure people are receiving good quality care to meet their needs. The staff we spoke with told us they have adequate time to complete training, they told us they can raise with leaders any additional training or support to meet their needs. Leaders told us policies in place where staff can learn from missed opportunities and poor performance is 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. However, during the on site inspection we found a gap in fire safety training where no staff member had completed this. Oversite of staff training wasn't effective as evidence wasn't readily available, staff members were collating certificates onsite to provide evidence to the inspection team.

The feedback we received was limited regarding infection control. However, patients told us the surgery was always clean, well maintained and they had no concerns regarding infection control.

Staff told us there was no outstanding actions from the infection prevention and control (IPC) audit in December 2023 and we confirmed this on site. Staff were knowledgeable in their roles and had undertaken a two day face to face training for IPC. Nurses told us they conducted further audits such as hand wash audits to ensure appropriate standards are maintained across all staff.

On the day of inspection we found the practice to be visibly clean and suitable personal protective equipment throughout the practice. We found posters around the practice including, sharps injury, handwashing and clinical waste to support good practice.

We found a list of annual audits which were adhered to, this ensured infection control was reviewed regularly. Actions from audits were completed in a timely way or the risk was mitigated when delays occurred. The practice had clear roles and responsibilities and staff were aware of these and the practice kept up to date with new risks to infection control which was shared with all staff.

The evidence we reviewed did not show any concerns about people’s experience regarding medicines optimisation at this practice.

Staff told us that they involved patients 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.

The practice ensured medicines were stored safely and securely with access restricted to authorised staff. Blank prescriptions were kept securely, and their use monitored in line with national guidance. Staff had the appropriate authorisations to administer medicines including Patient Group Directions or Patient Specific Directions. The practice held appropriate emergency medicines and a system was in place to monitor stock levels and expiry dates. There was medical oxygen and a defibrillator on site and systems to ensure these were regularly checked and fit for use. Vaccines were appropriately stored, monitored and transported in line with UKHSA guidance to ensure they remained safe and effective. The practice could demonstrate the prescribing competence of non-medical prescribers, and there was a regular review of their prescribing practice supported by annual appraisals, clinical supervision and named clinical supervisors.

There was a process for monitoring patients’ health in relation to the use of medicines including medicines that required monitoring (for example, warfarin, methotrexate and lithium) with appropriate monitoring and clinical review prior to prescribing. The remote review of patients who were prescribed medicines that required monitoring was generally well managed and showed patients received appropriate blood monitoring prior to medicines being prescribed. The practice had a system for recording and acting on safety alerts. We carried out a remote review of the clinical record system and found appropriate actions had been taken in response to safety alerts received.

The practice had a programme of targeted quality improvement and used information about care and treatment to make improvements. The practice shared their audit action plan which identified audits to be completed and by whom. Regular searches of the patient clinical system were made to ensure patient care and monitoring was completed in line with current guidelines.