- GP practice
Camphill Health Centre
Report from 5 June 2024 assessment
Contents
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
Safe
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.
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
Patient feedback regarding learning culture was limited. However, information we did receive was positive. Patients stated they felt listened to when they raised 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 staff and the service provided.
Information on how to make a complaint was displayed in the patient waiting area and on the practice website. Significant event reporting forms were available to all staff to access from the practice computer system. Staff were provided with access to a Freedom to Speak Up Guardian. Staff and leaders understood their responsibilities and how to identify and report concerns and safety incidents. Significant events and complaints were managed appropriately and staff were involved in identifying any learning. Feedback and learning from significant events and complaints was shared with staff via their managers and at staff meetings.
Safe systems, pathways and transitions
We could not collect evidence from patient feedback to score this evidence category. Our observations raised no concerns. 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 systems 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 were positive about their interactions with the practice, describing 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.
Safeguarding
We could not collect evidence from patient feedback to score this evidence category. Our observations raised no concerns . The evidence we reviewed did not show any concerns about people’s experience regarding safeguarding at this practice.
Staff were trained in safeguarding and had a clear understanding of their safeguarding responsibilities for reporting concerns. Staff were aware of the safeguarding lead and could access additional information within the practice to support them in taking action as required.
There were regular discussions between the practice and other health and social care professionals such as health visitors, school nurses, community midwives and social workers to support and protect adults and children at risk of significant harm. Partners told us about regular meetings that were held within the practice where safeguarding was discussed. They spoke positively of practice systems to ensure people were protected from abuse and neglect and that prompt action was taken when required.
The provider had systems and processes to ensure patients were safeguarded from harm. These processes were communicated to staff. Clinicians and staff were trained to appropriate levels for their role. There were systems to identify vulnerable patients on records. Disclosure and Barring Service (DBS) checks were undertaken when required. We gained remote access to patient records and found no risk associated with patients on the safeguarding register.
Involving people to manage risks
We could not collect evidence from patient feedback to score this evidence category. Our observations raised no concerns. 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 were informed about any risks and how to keep themselves safe through their treatment of conditions. Leaders told us about systems to regularly review consultations to ensure risks were managed whilst respecting patient choice.
The practice had multiple systems to support effective risk management. Routine clinical meetings shared identified risks and lessons learned. Formal risk assessments were routinely maintained and required actions were undertaken in a timely manner. Patients identified as at risk were involved in discussions and informed of options available to them to minimise risks.
Safe environments
Staff told us they felt safe to work at the practice and the facilities, equipment and technology were well-maintained so they could work safely and deliver a good standard of care to their patients. Leaders told us of action taken to protect staff and patients including the introduction of additional security measures on the entrance to the practice following a security incident.
We found no concerns regarding the location of the practice or the equipment held, which was maintained according to requirements. Patients appeared to face no difficulties physically accessing the service.
Risk assessments were undertaken as required to maintain a safe environment for patients and staff. Assessed risks were managed appropriately and in a timely manner.
Safe and effective staffing
Patients we spoke with and feedback we reviewed did not identify any concerns with staffing levels. Patients were complimentary about staff and the support they provided.
Leaders explained their recruitment processes to ensure appropriate numbers of suitably trained staff were employed to support the delivery of consistently safe, good quality care that met the needs of the patient population. Staff told us they received the support they needed to deliver safe care and that they could request additional training or support if needed.
There were various policies related to the management of the practice to help maintain a safe and effective workforce. This included recruitment, appraisal, supervision, incident reporting, performance management and training. There were systems to ensure staff with specific protected characteristics were not disadvantaged.
Infection prevention and control
Feedback we received from patients was limited regarding infection prevention and control (IPC). However, patients told us the surgery was always clean and well maintained. An inhouse survey undertaken by the practice in April 2024 found that 95% of patients rated the cleanliness of the practice as good, very good or excellent. The remaining 5% rated it as fair.
Staff were able to confidently discuss their responsibilities in relation to IPC. They were aware of who the IPC lead was and how to report IPC concerns. Leaders were able to discuss the processes to support effective management of IPC and that the service was transitioning to new IPC protocols which included more frequent and in-depth IPC audits.
The practice was visibly clean and suitable personal protective equipment (PPE) was available throughout the practice. Information posters were displayed including those related to sharps injury management, effective handwashing and clinical waste management to support good practice.
IPC policies were followed and audits 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, including a lead for IPC. Staff received role appropriate training.
Medicines optimisation
We could not collect specific evidence from patient feedback to score this evidence category. Our observations raised no concerns. 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.
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 systems ensured stock levels and expiry dates were monitored. 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 training.
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 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.
People’s medicines were appropriately prescribed, supplied and administered in line with the relevant legislation, current national guidance or best available evidence, and in line with the Mental Capacity Act 2005. Accurate, up-to-date information about people’s medicines was available, particularly when they moved between health and care settings, in line with current national guidance, when transferring between locations or changing levels of care. The remote review of patients who were prescribed medicines that required monitoring demonstrated the majority of patients received appropriate blood monitoring prior to medicines being prescribed. Our searches did identify a minority of patients who did not attend for regular reviews. We saw the practice made efforts to contact these patients and when necessary, took additional steps, including discussions in clinical meetings to reduce risks to these patients.