Doncaster Same Day Health Centre

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 a total of 8 quality statements from this key question. We have combined the scores for these areas with scores based on the rating from the last inspection, which was good. Our rating for this key question remains good. We found safety was a top priority, and staff took all concerns seriously. Safeguarding systems, processes and practices had been implemented. Staff had received safeguarding training relevant to their role and understood how to report concerns. Recruitment checks were carried out in accordance with regulations. When things went wrong, staff acted to ensure people remained safe. Managers investigated all reported incidents to reduce the likelihood of them happening again. Staff training was appropriate and up to date and staff had received induction, annual appraisal and clinical supervision. There was a positive learning culture. Staff knew how to identify and report concerns, safety incidents and near misses. The practice learned and made improvements when things went wrong. Staff supported people to live healthy lives and provided them with support and information on their care and treatment.

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 felt supported to raise concerns and felt staff treated them with compassion and understanding. The practice displayed feedback forms in the practice and information on how to make a complaint was available on site and on the practice website.

Managers encouraged staff to raise concerns when things went wrong. During staff meetings, the whole team discussed and learnt from clinical issues. Staff felt there was an open culture, and that safety was a top priority.

The provider had a significant event policy and complaints policy which was accessible to all staff members. The practice discussed events and incidents during team meetings and learning was shared with staff. The practice had a duty of candour policy and involved people when managing significant events and errors. The provider had processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Learning from incidents and complaints resulted in changes that improved care for others.

We did not receive any concerns from patients about delayed referrals or safe systems of care.

Patient booked their appointment via NHS 111 services or were referred by another service directly. Staff had a good understanding of local referral processes and arrangements. Staff told us they attended regular multidisciplinary team meetings where patients who may be vulnerable or those receiving end of life care were discussed and any actions agreed were recorded in patient records.

We did not receive any concerns from commissioners or other system partners about delayed referrals or safe systems of care.

The provider had appropriate processes in place for referral to secondary care and specialist services. We saw these were completed in a timely manner and there was cover in place when staff who carried out this role were absent. There were clear processes in place for taking action when the provider received letters or discharge summaries from the hospital. Any actions required from these were forwarded to the appropriate person to take action for example, the relevant GP who they patient was registered with.

Staff told us they had received training in safeguarding children and adults and we saw records that confirmed this. They knew who the safeguarding lead in the service was and how to raise concerns. Staff told us they attended regular safeguarding multidisciplinary team meetings and we saw minutes from meeting that confirmed this.

We did not receive any concerns from commissioners or other system partners about safeguarding systems and processes.

All staff had received training in safeguarding children to the appropriate level for their role in line with the Safeguarding Children guidance. All staff had received adult safeguarding training. There was a safeguarding policy in place which was accessible to all staff on the practice’s computer system. The practice held regular safeguarding multidisciplinary team meetings. The practice held regular safeguarding multidisciplinary team meetings. We saw minutes of these meetings and observed any actions discussed were recorded in individual patient records on their clinical system.

We did not receive any feedback from members of the public regarding this service. The evidence we reviewed did not show any concerns about people’s experience of involving people in managing risks. The provider had implemented a quality improvement audit system in place which allowed patients the opportunity to provide feedback on the service received. The way they managed feedback showed the views of people were listened to and considered.

The provider had implemented a quality improvement audit system in place which allowed them to regularly review patient consultations to ensure risks were managed whilst respecting patient choice. For example, a monthly wound referral system was in place to monitor and record outcomes.

Clinicians had access to patient information to enable them to deliver safe care and treatment. There were systems for sharing information with a patient’s GP and other agencies to help manage risk. People were informed about any risks and how to keep themselves safe. Risks were assessed, and people and staff understood them.

Staff told us they felt safe to work at the service. They said that facilities, equipment, and technology were well-maintained so they could work safely and deliver a good quality of care to their patients. Staff had completed training in fire awareness.

We carried out a walk around of the premises on our site visit and saw the environment was satisfactorily maintained, for example, the emergency equipment medication, appropriate calibration of equipment and portable appliance testing (PAT). The practice was clean, and we saw the premises was free from safety obstructions and was accessible. However, we saw that the lift to the first floor was out of order at our time of the site visit. We spoke to the manager and they assured us that a contractor had been sourced for the repair and replacement of parts. There was no potential risk to patients as all access to clinicians and patient services were on a ground floor level and the lift to the first floor was for staff and administration use only.

The service had monitoring systems in place which they reviewed regularly to ensure risk assessments and actions from the assessments were completed. The service had systems in place to report new and emerging risks should they occur. We saw that health and safety and fire risk assessments had been carried out. There was a fire procedure.

We did not receive any feedback from members of the public regarding this service. The evidence we reviewed did not show any concerns about people’s experience of involving people in managing risks. The provider had arrangements in place to allow patients the opportunity to provide feedback on the service received. The way they managed feedback showed the views of people were listened to and considered.

The management structure and strategy across the service had changed significantly as they had recently implemented a new management structure from January 2024. Leaders described the structure with clear lines of accountability and support for staff. Considerable focus had been placed on ensuring the right structure was in place to ensure safe and effective staffing arrangements. The staff we spoke with told us they had adequate time to complete training, and they could approach leaders to access any additional training or support to meet their needs. They said that one of the benefits of their workplace was the support they received from the whole team.

There was robust and safe recruitment practices to make sure that all staff were suitably experienced, competent, and able to carry out their role. Staff completed training appropriate and relevant to their role. We saw the provider had a recruitment policy which was updated regularly. Recruitment checks were carried out. We sampled recruitment checks for both staff and GPs and saw that checks had been undertaken prior to employment.

People were protected as much as possible from the risk of infection because premises and equipment were kept clean and hygienic. During the site visits, we found the areas where the service was delivered to be visibly clean and suitable personal protective equipment throughout the practice. Equipment was managed appropriately, for example, sharps bins were available in all clinical rooms; signed, dated safely sited & not over-filled. The process for managing clinical waste was explained.

There was an effective approach to assessing and managing the risk of infection, which was in line with current relevant national guidance. Infection Prevention and Control (IPC) audits were carried out at a minimum of six-monthly intervals. Actions from audits were completed in a timely way. Appropriate standards of cleanliness and hygiene were followed. Staff had received the appropriate infection control training.

Staff managed medicines safely and regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines. Staff showed how they disposed of expired or unwanted medicines that patients had returned. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments. The provider had systems in place to receive, review and act on medicine alerts which were issued and managed by a central governance team.

Accurate, up-to-date information about people’s medicines was available as clinicians and enhanced access staff had access to the patient’s clinical records. The provider was monitoring medicine prescribing in the form of audits. For example, opioids, and antibiotic prescribing were taking place regularly. The service completed regular monitoring of medicines which required refrigeration. The service did not dispense any medicines and did not hold any controlled drugs. Prescriptions were sent electronically to a pharmacy of the patient’s choice for dispensing. The provider had effective systems to manage and respond to safety alerts and medicine recalls.