Willaston 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 monitored and reviewed safety using information from a variety of sources. There was a positive learning culture. There was a system for recording and acting on significant events. Staff knew how to identify and report concerns and safety incidents. The provider learned and made improvements when things went wrong. Appropriate systems for the safe management of medicines including emergency medicines and equipment and medicines optimisation were in place and mostly effective. We reviewed patients’ clinical records and found some patients were overdue monitoring. The provider was responsive and promptly acted on the concerns found during our assessment.

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.

People told us they felt the provider was receptive to feedback and actioned improvements where they were identified. Ways to provide feedback were advertised at the practice, on the provider website and in a local newspaper. Information on how to make a complaint was available on site and on the provider website.

Staff demonstrated a good understanding of how to report incidents, raise concerns and we saw that there were regular discussions in staff meetings to identify learning. Staff and leaders were able to share examples of incidents and complaints and the appropriate action that had been taken as a result. We saw that leaders used incidents and complaints to improve systems and processes.

The provider monitored and reviewed safety using information from a variety of sources and had clear policies and procedures to support staff to manage this information. There was a system for recording and acting on significant events and safety alerts. There was a culture of learning with staff encouraged to report concerns for the whole team to learn. Between May 2023 to April 2024 the practice recorded 14 events that had been investigated and learning shared as appropriate. The provider had a complaints policy in place and information was accessible to patients in various formats. The complaints we reviewed showed they were recorded and investigated appropriately. Patients received a final response which included details of the process if they wanted to escalate their complaint. Learning from complaints was identified and monitored to completion in a timely manner.

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.

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.

The patients we spoke to during our assessment did not give any comment specifically regarding medicines optimisation.

Staff and leaders told us and demonstrated that they had systems and processes in place to support the safe prescribing of medicines. They told us about plans for ongoing monitoring of the service to improve these processes. At the time of the assessment the provider was recruiting staff to improve the oversight and management of medicines. Prescribing and medicines management were discussed regularly during clinical meetings.

As part of the assessment, we conducted searches on the practice clinical system and reviewed a selection of patients’ records. We found some improvements were required with monitoring of patients prescribed high risk medications and for documentation of medicine reviews. The provider took action and had a plan for addressing the areas identified. During our site visit we found storage and management of medicines, including those held on site in case of an emergency, was appropriate. The practice had systems in place to receive, review and act on medicine alerts however we found some action was required to ensure clinicians were up to date and acting on all information shared.

The provider had policies and systems to support management of medicines. There was a process for monitoring patients’ health in relation to the use of medicines including medicines that require monitoring however some issues with the oversight of this were identified. Staff had the appropriate authorisations to administer medicines (including Patient Group Directions or Patient Specific Directions). Staff were up to date with relevant training with regards to medicines management. A system was in place to monitor stock levels and expiry dates of medicines held on site. Vaccines were appropriately stored, monitored, and transported in line with guidance to ensure they remained safe and effective.

We reviewed clinical records for patients who had been prescribed medicines which required routine monitoring. Our review found some improvements were required to ensure patients had all been monitored and reviewed in line with current clinical guidelines. The practice was responsive and promptly acted on the concerns found through our searches. This included producing an action plan that included a review of medicines management and additional audits planned.