Alexandra Road Surgery Also known as Alexandra and Crestview Surgeries

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 all 8 quality statements and 22 evidence categories from this key question. Our rating for this key question is good. We found safety was well managed, and staff took all concerns seriously. When things went wrong, staff acted to ensure people remained safe. Managers investigated all reported incidents to reduce the likelihood of them happening again and shared their findings with all staff to learn and improve.

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.

Staff told us there was a proactive and positive culture of safety based on learning from concerns about safety. Safety events were investigated and reported thorough staff meetings to learn lessons and reduce an occurrence.

The provider had processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints, when things went wrong. Learning from incidents and complaints resulted in actions that improved patient care and outcomes.

Staff told us they worked with patients and partners to keep people safe, this included continuity of care when people moved between different services.

The provider had established and maintained systems to ensure safety was managed, monitored, and assured.

The provider worked with the practices in their primary care network to understand what safe meant for them and their patients. Staff worked to protect peoples’ rights to live safely, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. Staff communicated how they shared concerns to the safeguarding led quickly and appropriately.

Partners told us they would have no concerns raising a safeguarding concern and would be confident with the practice capacity to manage concerns well.

We were provided the practice safeguarding policy, and found staff knew how to access it when needed during the site visit.

Staff told us they worked with people to understand and manage risks. We saw care was provided to meet patients’ needs in a safe and supportive way.

The provider had asked for people’s feedback and had acted on the responses. Assurance of the providers actions was evidenced to us in their “You said” “We listened” document.

Staff told us the regular safety risk assessments they carried out ensured the practice equipment and facilities kept people safe.

We saw equipment, facilities and technology at the practice supported the delivery of safe care.

The provider had systems and risk assessments to detect and control potential risks at the practices.

Staff told us the provider carried out competency checks to ensure staff were effective and patients were safe.

We found the provider had clear and effective processes to recruit and induct staff. Staff records showed effective checks had been carried out prior to staff working at the practice this included clinicians registration details.

Staff told us how they assessed and managed the risk of infection. The updated and recently reviewed infection control policy was clear about how staff shared any concerns with appropriate agencies promptly and the controls at the practice.

The environment was seen to be clean and safe during the onsite visit. We saw the provider had systems to monitor infection control risks and took actions when they were needed.

We found the policy and procedures carried out at the practice were safe and effective to manage infection control.

Staff involved people when reviewing their medicines and helped them understand how to manage their medicines safely. People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms.

Staff received regular medicines management training, and felt confident to manage, administer and record the use of medicines. Medicines-related stationery was appropriately stored and secure. During the remote searches we carried out on the patient record system as part of the assessment, we identified that staff followed current clinical guidelines. This ensured they prescribed all medicines safely and patients received regular, appropriate, and timely medicine reviews and monitoring.

Staff managed medicines safely and regularly checked the stock levels, expiry dates, and temperature control for all medicines including emergency medicines, vaccines, and controlled drugs. Staff stored medical gases, such as oxygen, safely and completed the appropriate safety risk assessments.

The provider had effective systems to manage and respond to safety alerts and medicine recalls. Staff followed established processes to ensure people prescribed medicines with specific monitoring needs received the recommended observations.

Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, this included antibiotic stewardship. This was confirmed when we reviewed the prescribing data as part of our assessment. For example, the number of antimicrobial's issued by the provider was lower than local averages and equal to national averages. We saw regular clinical auditing of prescribing that was focused on improving care and treatment.