Cavendish 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 looked for evidence that people were protected from abuse and avoidable harm. We assessed all the quality statements from this key question. At our last assessment, we rated this key question as good. At this assessment, the rating remains the same.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Leaders informed us they had processes and systems in place to report, investigate, and learn from significant events, complaints, or incidents that occurred.

Staff told us they knew how to identify and report concerns, safety incidents, and near misses. They were able to raise concerns when things went wrong, and shared examples of improvements made following incidents and complaints. Staff felt there was an open culture, and confirmed they had weekly meetings where they discussed incidents and learning. We reviewed a sample of minutes of various practice meetings and were satisfied that they were appropriate and included learning.

Representatives from the Patient Participation Group (PPG) felt the practice took concerns seriously and proactively made improvements to the service. Managers encouraged staff to raise concerns when things went wrong and when things went wrong, staff apologised and gave people support. Learning from incidents and complaints resulted in changes that improved care for others.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services, as some patients had input from the private sector. Patients did not raise any concerns regarding safe systems of care operated by the practice.

The leaders explained they had oversight of the workflow tasks to ensure they were all responded to promptly. On the day of the assessment, we did not find any delays in the patient workflow tasks. There were processes in place to act on correspondence received by the practice with a designated member of the team having oversight. Leaders arranged for staff to complete training in GP coding to help with managing the workflow for the clinical team.

The leaders submitted safeguarding children and vulnerable adults policies. Both policies were last reviewed in February 2025, which were appropriate and included all key information, to ensure there was a safe system to identify, review, and safeguard patients. The practice has a policy of registering the whole household for children on the safeguarding register, with monthly searches put in place to regularly update this. We saw that children on the child protection plans were coded accordingly and leaders informed us they cross checked this with social services.. People who provided feedback for this assessment had no specific views or concerns in this area.

The practice had a system to highlight vulnerable adults and children on their medical records. There were regular meetings between the practice and other health and social care professionals, such as health visitors and District nurses, to support and protect adults and children at risk of significant harm. We reviewed safeguarding multidisciplinary team meeting minutes. Staff explained they had a system to follow up with children who were not brought to appointments and AE attendances to identify any patterns as per the practice’s Was Not Brought (WNB) Policy.

The practice had a safeguarding register which was maintained by one of the partners who was also the safeguarding lead. Safeguarding policies and procedures were available and accessible to all staff. Staff knew who the safeguarding lead was and how to report any concerns. The safeguarding lead also attended borough wide safeguarding meetings that focused on dealing with complex cases and updated the team during weekly meetings. We reviewed four staff files and found safeguarding training was provided appropriately and staff had completed the correct level of safeguarding training for their role. Staff had additional training in domestic violence and the practice has searches in place to identify this vulnerable group. The leaders told us that they had systems and process that are monitored weekly and monthly for their vulnerable patients.

During the assessment, it was identified that reception staff needed further support with sepsis awareness in addition to the mandatory training they had. Following the inspection leaders sent us evidence that further sepsis training had been provided and this will be a regular occurrence. Staff provided care to meet people’s needs that was safe, and supportive and enabled people to do the things that mattered to them. Emergency equipment and medicines were available and checked regularly to ensure they were in date.

The practice had guidance for staff to identify people with immediate life-threatening conditions and people whose health was deteriorating. This included immediate advice to give people and how to escalate risk to an appropriate clinician. The practice had a duty GP every day who was available for advice and support as necessary. All staff had completed basic life support, and anaphylaxis training relevant to their role.

Leaders at the service were able to detail the policies and procedures that were in place to ensure that the environment was safe. During the assessment, we reviewed the practice’s premises safety processes.

The practice was situated in a purpose-built building shared with the local authority. The practice was based in the basement area of the building. We observed that the clinical rooms and offices used by the GP practice were fit for use, with appropriate ventilation and lighting throughout. All equipment had been checked and calibrated as required. The practice had all the required emergency medicines and equipment in place to ensure that emergencies could be safely managed. Staff were aware of what to do in an emergency and where emergency medicines and equipment were stored. Allocated staff also knew how to safely manage spillages of bodily fluids.

The practice had arrangements in place to ensure the premises were maintained. We observed fire exits were clear and fire safety equipment was easily available andregularly checked by an external company. The practice had completed health and safety, legionella, and fire risk assessments. Checks of electrical safety and equipment calibration were also completed. There was a business continuity plan in place which was monitored and reviewed. The practice had undertaken a full range of risk assessments to ensure the premises was maintained and that the environment was safe, including health and safety.

The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Leaders informed us they had processes and systems in place to report, investigate, and learn from significant events, complaints, or incidents that occurred.

Staff told us they knew how to identify and report concerns, safety incidents, and near misses. They were able to raise concerns when things went wrong, and shared examples of improvements made following incidents and complaints. Staff felt there was an open culture, and confirmed they had weekly meetings where they discussed incidents and learning. We reviewed a sample of minutes of various practice meetings and were satisfied that they were appropriate and included learning.

Representatives from the Patient Participation Group (PPG) felt the practice took concerns seriously and proactively made improvements to the service. Managers encouraged staff to raise concerns when things went wrong and when things went wrong, staff apologised and gave people support. Learning from incidents and complaints resulted in changes that improved care for others.

The practice ensured that facilities and equipment were safe, and that equipment was maintained according to manufacturers’ instructions. A legionella risk assessment was in place.There were systems for safely managing healthcare waste. Cleaning schedules were in place and followed and the practice also had an external company for this. The premises were visually clean, hygienic, and uncluttered. Patients told us the practice was always clean and well-maintained.

Policies and procedures were available to staff, which provided guidance and information on infection prevention control (IPC) practices. The practice had a designated IPC lead. Staff had completed the infection prevention and control training relevant to their role.

Our GP specialist advisor carried out a remote review of the clinical record system and the searches indicated that prescribing was adequate and in line with national guidance, with the exception of lithium, and azathioprine. Our review found that 4 patients were prescribed lithium, which is a high risk mood stabiliser, and from the sample of 4, 2 patients were overdue bloods monitoring which should be carried out within 12 weeks. Clinical searches found 2 patients who didn’t have the required monitoring for azathioprine, which is an immunosuppressant drug. There was evidence that the practice was trying to arrange for a shared care agreement with the hospital, as patients had been prescribed the medicine from hospital consultants. The service immediately took appropriate action to address the concerns raised by putting in place the necessary systems and processes to manage this, such as a regular automated searches and designated clinicians for the prescribing of high risk medicines.

We reviewed the practice’s clinical audits conducted within the last year and found that they were carried out appropriately and contributed to improvement. There were regular audits of prescribing that focused on improving care and treatment. Staff took steps to ensure they prescribed antimicrobials appropriately to optimise care outcomes, prescribing data reviewed as part of our assessment confirmed this. For example, the number of antimicrobials issued by the practice was lower than local and national averages.

The practice had effective systems to manage and respond to safety alerts and medicine recalls. The practice’s latest prescribing performance data showed that it achieved above the local averages in four of the six indicators and in line with the local averages in the remaining two indicators.

The practice stored medicines including controlled drugs, securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines, vaccines, and controlled drugs. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments.