Hope House 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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

This is the first inspection for this service since its registration with CQC. This key question has been rated as Good.

The service had a good learning culture and people could raise concerns. Leaders investigated incidents thoroughly. There were enough staff with the right skills, qualifications and experience. Leaders made sure staff received training and regular appraisals to maintain high-quality care. Staff managed medicines well and involved people in planning any changes.

This service scored 72 (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. Lessons were learnt to continually identify and embed good practice.

Staff were encouraged to raise concerns when things went wrong. They told us significant events, complaints and examples of feedback were shared and discussed during regular meetings. Staff felt there was an open culture and understood their duty to raise concerns and report incidents. Leaders provided examples of how incidents were investigated and resolved.

There were policies and processes in place to record, investigate and take action from incidents and complaints. These were discussed in monthly governance meetings and minutes made available to staff who were unable to attend. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support in line with the duty of candour. Learning from incidents and complaints resulted in changes that improved care for people who used the service.

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. The service was supported by care co-ordinators and a social prescriber within the local primary care network (PCN). These roles were effective in bringing together multidisciplinary teams to support people with complex health and care needs, such as arranging appropriate support via service referrals. There were systems for processing information relating to newly registered people. The service worked with other providers to deliver shared care and when people moved between services. Referrals and test results were managed in a timely way. Policies and guidance were in place to support workflow and pathways for appointments, referrals, records and correspondence. The service had a system for processing new information and summarisation of notes.

Staff told us they were aware of their role to monitor and manage care when people moved between services, such as after referral to secondary care, or admission to hospital. A review of the service’s clinical system, which formed part of this assessment, indicated people’s test results were being managed in a timely manner to support transition through services. For example, people received a streamlined transition from the community mental health service when care came to an end through the dedicated mental health practitioners at the service who managed care-planning arrangements.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

There were designated safeguarding children and adult leads at the service. There were six-weekly multi-disciplinary meetings where safeguarding issues were discussed, and these were attended by clinical and management staff. External stakeholders were invited to safeguarding meetings where relevant, such as community nursing teams and health visitors. Systems were in place to appropriately refer people to the local authorities and information was shared amongst community teams where required. Safeguarding and chaperoning policies were accessible to staff.

Clinical staff members had chaperone responsibilities as part of their role. All staff members had completed Disclosure and Barring Service (DBS) checks to ensure they would be appropriate to undertake this role.

All members of staff were up to date with safeguarding training in addition to the Mental Capacity Act and the Deprivation of Liberty Safeguards which were mandatory in line with the service’s policy.

We reviewed a sample of people’s records as part of our remote clinical searches and saw care plans noted how people were to be supported to remain safe. There were safe systems and processes in place to ensure children had been appropriately followed up with when they failed to attend appointments.

The service worked with people to understand and manage risks. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. The service had maintained emergency equipment and staff were aware of procedures including recognising a deteriorating patient and were trained on relevant actions to take. People were advised on risks related to their condition and actions to take if their condition worsened.

The service had a dedicated workflow team comprised of administrative staff which supported correspondence and patient communications. Staff told us urgent tasks were raised to GPs based on information escalated by Out of Hours and NHS 111 services, particularly, for people who were required to be seen in-hours by the service based on their symptoms and clinical presentation.

Leaders demonstrated the arrangements for reviewing abnormal results were prioritised to ensure people were followed up in a timely way. For example, we observed the service’s pathology clinical system mailbox and identified abnormal results were assigned appropriately. This was either to the requesting clinician or to the duty GP for review on the day via a ‘buddy system’ to prevent delays to care and treatment. Staff were able to describe their roles and responsibilities to manage risks associated with workflow and patient correspondence.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Premises and equipment were otherwise well-maintained, including regular portable appliance testing, equipment calibration and fire safety equipment servicing. The service had a business continuity plan which was monitored and reviewed regularly.

The service had retained and stored all Control of Substances Hazardous to Health (COSSH) risk assessments for all cleaning products stocked, alongside relevant Safety Data Sheets (SDS).

However, the service experienced ongoing issues with the premises due to incomplete and unresolved construction work since 2022. Despite taking all reasonable steps to identify and mitigate associated risks, the environment continued to fall short of required safety standards. The service actively engaged with external surveyors to assess necessary remedial actions and worked closely with the local commissioners to address and resolve the outstanding issues. We noted examples of where the premises had posed risks to the health and safety of people such as a leaking floor on the first floor which had caused laminate to rise as well as unlevelled and lack of drainage in the car park, which had caused flooding. This presented health and safety risks from structural damage, and trip hazards which the service had identified, assessed and implemented temporary remedial actions whilst awaiting further clarification of the extent of the works required to rectify the shortfalls in health and safety standards.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Staff told us the service ensured staff were supported in their roles. Supervision and development was in place through appraisals. The service had started to embed new supervision processes for its’ non-medical prescribing staff. The service had demonstrated examples of how cases had been reviewed by a GP supervisor and discussed the quality of care to ensure prescribing was in line with national guidelines.

Staff could discuss clinical queries in relation to their medicine prescribing or care and treatment planning with leaders who they said had an ‘open door’ policy. There were daily slots available for clinicians to seek support with the on-the-day duty GP. The service had named supervisors for the medical students at the service under their education placements.

Staff received a formal induction relevant to their role and responsibilities and were supported through ongoing appraisals. There were systems in place to monitor staff training compliance, and all staff had completed mandatory training in line with service policy. This included requirements set out in statutory training for learning disabilities and autism spectrum disorder (ASD). The service had ensured all staff had completed e-learning with planned co-delivery with people with lived experiences of learning disabilities and ASD to carry out interactive sessions for those staff assessed as providing direct care and support. Lived experience face to face training had been completed by 32 of the 36 (89%) patient facing staff. Of the 4 staff yet to complete it, 2 had been on long-term leave prior to September 2025.

All recruitment and Human Resource (HR) records were kept in-line with service policy and Schedule 3 requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We carried out a review of the provider’s recruitment checks in relation to 3 members of staff and information was available and up to date in line with service policy.

There were staffing arrangements to ensure in the event of an emergency, the risk of unsafe practice was mitigated and prevented lone working.

There were staffing arrangements to ensure in the event of an emergency, the risk of unsafe practice was mitigated and prevented lone working.

The service did not always assess or manage the risk of infection via cleaning standards effectively. They did not always detect and control the risk or share concerns with appropriate cleaning contractors promptly. For example, we observed cleaning mop heads appeared visibly dirty. The service was unable to demonstrate mop heads were suitably disinfected and cleaned in line with service policy and national standards of healthcare cleanliness, as records of regular audits of cleaning standards were not kept. After the assessment, the service demonstrated cleaning performance was reviewed with the external cleaning contractor and provided records to ensure hygiene standards were being met.

The service had carried out a legionella service assessment in February 2025. The service had a monthly water temperature sampling regime in place. However, the service had not tested and recorded cold-water temperatures in the relevant rooms to demonstrate water temperatures were controlled to prevent the growth of legionella bacteria. To comply with the Health Safety at Work Act 1974, hot water should be stored at 60 degrees Celsius or above, distributed at 50 degrees Celsius or above, and cold water below 20 degrees Celsius. After the onsite visit, the service improved its’ safe water procedures to include cold water temperature checks.

However, the service had a designated infection, prevention and control (IPC) lead and all staff had received relevant training. Risk assessments and audits were completed, and we saw improvements had been made to the premises identified by the service. Clinical waste arrangements were in line with waste management national guidelines.

The service made sure medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

During our remote clinical searches, we noted people who had been prescribed high-risk medicines had been appropriately monitored and reviewed in line with national guidelines.

Patient Group Directions (PGD), a legal document that allows certain healthcare professionals to supply or administer a specific medicine to a pre-defined group of patients without an individual prescription, and Patient Specific Directions (PSD), a written instruction from a prescriber for a medicine to be supplied or administered to one or more named patients, were in place which relevant staff worked to. Prescription stationery was logged and stored securely.

Medicines were stored securely and the service held appropriate emergency equipment and medicines. The service maintained appropriate fridge temperature records where vaccines were being stored and cold-chain protocols were followed.

Leaders demonstrated there was an effective system to ensure safety alerts were acted upon in a safe way to people. During our remote clinical searches, we noted people who were subject to medicine safety alerts were contacted to inform them on the risks and prescriptions were reviewed appropriately.

Although people received timely medicine reviews, we found documentation did not always include sufficient information to support future care planning. The service had demonstrated medicine reviews formed part of clinical supervision and appraisal processes to improve the quality of care delivered by clinicians and for learning purposes.