Adelaide 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

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

The service was in breach of legal regulations in relation to safe care and treatment and fit and proper persons employed.

This service scored 31 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice did not always have a proactive and positive culture of safety based on openness and honesty. They did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

There was no monitoring of significant events (SEAs) as they were not collated to show what had been received and when any action was completed. Blank SEA forms did not give enough prompts for people to adequately record relevant information. We reviewed the 10 forms completed in the past year. There was no evidence of any investigations taking place, and often no evidence that anyone other than the person completing the form had been involved. There was no evidence of SEAs being reviewed, and learning was usually not identified, documented or shared. Of the completed forms we reviewed, it was not always clear what the issue had been.

Of the 24 staff we received feedback from, 13 stated they were not invited to meetings where SEAs were discussed. The practice was unable to locate the majority of meeting minutes so we could not see evidence they were discussed by partners or leaders. However, we saw meeting minutes from a reception meeting at 1 of the sites in May 2025 where 2 SEAs were briefly mentioned. Neither of these incidents were formally recorded as significant events. During the assessment different staff told us about 3 separate SEAs that we could find no record for. The practice manager told us none had been completed.

The practice had a significant event policy that included examples of incidents that might trigger a SEA. These included new cancer diagnoses, violent or aggressive patients and breaches of confidentiality. We saw examples of this type of incident, and none had been recorded as an SEA.

The practice did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services.

The practice had a cabinet which contained the records of patients who had registered with them. These were awaiting summarising, including extracting key medical information from paper records and accurately transcribing it into the patient's electronic medical record system. This is required to provide safe and informed healthcare. The records were not stored in any order. The practice manager told us these were not monitored, and they did not know how long the oldest one had been there for. We found records dating back to March 2024.

The practice told us urgent referrals were usually actioned on the day they were requested, but there had recently been a backlog due to a whole staff group being absent from work at the same time. Senior leaders told us they did not monitor referrals to ensure patients had attended their appointment. They said they told us they informed patients they should contact the practice if they had not heard about their referral within 2 weeks. Following the assessment the provider told us a referral tracker had been in place. There had been a complaint about a referral that had been missed. This had been due to there being no staff available to process the referral. The practice had not raised a significant event or ensured a system was in place to prevent this happening again.

Our clinical searches found that some pathology results had been awaiting action for over a month. The practice told us one of the managers was off work and that had impacted on the actioning of pathology results.

The practice did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They did not always share concerns quickly and appropriately.

The practice had a Safeguarding Children policy, but the names of the practice safeguarding leads were not included in the policy. The Freedom to Speak Up Guardians named in the policy were incorrect. The Safeguarding Adults policy had been reviewed in October 2024 but still referred to Clinical Commissioning Groups, which were abolished in July 2022.

Not all staff were aware of who the safeguarding leads were.

The practice maintained a list of vulnerable people and told us they acted on concerns working in partnership with other organisations. We were told there was a new system to provide assurance that appropriate safeguarding actions had been taken, and outcomes were recorded. However, we were unable to view this because during the assessment the non-clinical safeguarding lead was not available and other staff, including managers, did not know how to access this.Following the assessment the provider sent us evidence of the system in place to monitor all aspects of safeguarding.

The practice did not have an effective system to triage patients in order to prioritise needs when allocating appointments. We were given conflicting information by different GP partners, staff and managers about the system in place, with 1 partner telling us that the practice was aspiring for reception to triage service users and provide care navigation, but it was not in place yet. We saw a triage form, but staff and managers told us it was not being used due to the practice being short-staffed. Some staff told us they had been on care navigation training, but some told us this had not been provided. Evidence of care navigation training was not in any of the training records we saw. Therefore, there was no assurance that patients were receiving care and treatment in line with their needs.

The practice did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

There were 3 fire wardens that worked between the 3 sites. There was no system to ensure there was always a fire warden available at each site. The practice supplied us with information about staff training. There was no training information available for 1 of the fire wardens, so no evidence they were appropriately trained.

There were regular checks of the fire alarm at each site, and fire evacuations had taken place. However, the staff member responsible for some checks, such as emergency lighting, had recently left and these checks had not been reallocated to anyone else. There was no evidence of regular checks of fire doors and means of exit.

On 1 site the boiler room was accessed directly from the waiting area. This room was unlocked and contained items that could be dangerous. The practice manager told us it was usually locked. We also saw a room used as an office that was uncomfortably hot. Staff working at the site told us air conditioning had been requested but refused.

Fire risk assessments had been carried out the month prior to our assessment, and most actions had been completed. Health and safety risk assessments had also been carried out, although for 1 site it was recorded as being carried out on a date in the future. The practice manager told us there was no policy for how often risk assessments should take place, and they did them when they thought it was necessary.

It was usual for keys to be issued to staff on their first day of work if they were to be responsible for opening the buildings. This was before relevant training had taken place, and in some cases without evidence of the identity or full details of the staff member being held. The practice manager told us they thought staff should pass their probation before being a key holder, but they had been told new staff were required to open buildings.

There was a business continuity plan in place which was monitored and reviewed.

The practice did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

The practice held some staff records on paper and some electronically, and they were unclear what was kept for each staff member. The practice manager told us they had been trying to transfer information, so it was all held electronically, but this had not been possible due to being short-staffed. They told us they were aware some required information was missing as they had been unable to locate it when they started the role.

We checked a selection of paper and electronic records held for staff, and the practice manager confirmed we had checked everything they held for each of them. There was no record of a Disclosure and Barring Service (DBS) check having taken place for all clinical staff. Proof of identity including a recent photograph was not held for all staff. Routine checks were not carried out to ensure clinicians were registered with the appropriate regulatory body, and where we saw checks had been completed, they were from several years ago. Evidence of the qualifications of clinicians was not always available. There were not always employment histories available, gaps in employment had not been explained or queried, and references had not always been sought. Where a DBS disclosure had recorded a previous conviction there was no record of this being considered or a risk assessment taking place to assess the staff member’s suitability to the role. For this staff member no evidence of identity, references or employment history was held. The required checks for locum GPs had also not been carried out.

Staff appraisals were not up to date. Where held they did not contain sufficient detail, and some were not dated or did not include the name of the appraiser. GP partners told us they did not carry out any structured or documented supervision of clinical staff, but they saw them regularly to look at patient consultations and were available for any queries. Staff feedback contradicted this.

Over half of the staff members we asked told us they did not think there were enough staff to provide safe, high-quality care. The practice manager agreed with this and said it had been a challenge. Several staff were off work sick, had just left or had resigned recently. Staff told us their roles were not covered if they were off work.

The practice manager told us there was no formal induction for new staff, and no induction records were kept.

Although we saw most mandatory training was up to date, not all staff were included on the training records we were provided with. Staff told us they struggled completing training as they were too busy.

The practice did not assess or manage the risk of infection. They did not detect and control the risk of it spreading.

The practice had an infection prevention and control (IPC) policy. This had been updated following our request to see it. It did not contain enough information to guide staff, and it was not followed.

The policy stated all staff had been trained in aspects of IPC, but it did not state at what level training was required. It stated, “All staff involved directly or indirectly in patient care will attend an annual infection control training session that includes sharps handling and management of body fluid spills/splashes. Training records will be maintained.” This was not happening.

The policy stated a risk assessment for infection control risks had been completed and an action plan put in place, but it did not state how often risk assessments should be carried out.

The policy stated that “clinical hand wash basins (elbow taps, no plug) will be available where clinical care takes place”. This was not the case. Some basins had plugs on chains, and where this was the case the plugs and chains were dirty.

Privacy curtains in clinical rooms were not being changed every 6 months in line with the practice’s policy.

The practice supplied us with a hand hygiene audit which had been completed the week of our site visits. Only staff available on that day had been audited and the practice said they did not have any previous audits.

The practice did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Practice nurses had not been authorised to administer certain medicines. We checked 5 Patient Group Directions (PGDs), which are formal documents to authorise healthcare professionals to supply and/or administer specified medicines to patients without a specific prescription from a doctor. None of these had been authorised.

The practice’s prescription security policy stated that prescription pads were issued to GPs each morning and the GPs should record how many prescriptions were in their pads. This did not happen. A GP told us they signed for prescription pads and then signed for another when the pad had been used. Blank prescriptions were not being held securely. Prescription logs were inaccurate. It was not possible to determine how many pads existed, or what pads were in the possession of GPs. Staff confirmed that prescription pads should be signed back from GPs daily, but they did not know which GPs were in possession of prescription pads, so it was not possible for them to determine if any prescriptions had been misappropriated.

The practice could not provide assurance that medicines were kept at the appropriate temperatures to ensure they were effective and to avoid potentially harming people. The temperatures of medicine fridges were recorded daily, but there were no checks to ensure action had been taken if they were outside the appropriate temperature range. The staff recording the temperatures did not know how to check previous records, only how to record the daily temperature. Where it had been identified the medicine fridge had gone above the appropriate temperature, a note had been attached to the fridge instructing staff not to use the medicines. However, there was no record of any action being taken to check the safety of the medicines to decide if they should be destroyed.

Emergency medicines were held, but where the practice had decided not to stock all the suggested emergency medicines no risk assessment had been carried out. The practice put this in place following the assessment.

We carried out a series of searches on the practice’s clinical systems as part of this assessment. We reviewed clinical records for patients who had been prescribed medicines which required routine monitoring.

Our clinical searches looked at patients prescribed Amiodarone (a medicineused to treat heart rhythm problems). There were 8 patients prescribed Amiodarone, and our searches found 6 had not had the required monitoring. We checked 5 in detail. Of these, 4 had never had their magnesium levels checked, and the 5th was no longer being prescribed Amiodarone. Low magnesium levels can significantly increase the risk of serious heart rhythm abnormalities.

Our clinical searches found people prescribed nonsteroidal anti-inflammatory drugs (NSAIDs, used to reduce inflammation and pain) were not prescribed Protein Pump Inhibitors (PPIs) to decrease the risk of gastro-intestinal bleeding. 125 patients were prescribed NSAIDs, and we checked 5 in detail. None of the 5 had been prescribed a PPI, and all 5 were at a higher risk of having a gastro-intestinal bleed.