Island City Practice Also known as Lake Road Practice

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

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 practice 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. People felt supported to raise concerns and felt staff treated them with compassion and understanding. Representatives from the Patient Participation Group (PPG) felt the provider took concerns seriously and proactively made improvements to the practice. 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 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.

The practice 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 practices. There were systems in place for processing information relating to new patients. The practice worked with other providers to deliver shared care and when patients moved between practices. Referrals and test results were managed in a timely way. Clinical meetings were well attended by a broad range of clinicians and held monthly We found there was a collaborative, joined-up approach to people’s care.

The practice 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 practice shared concerns quickly and appropriately. Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. The provider made sure that children had been appropriately followed up with when they failed to attend appointments with primary and or secondary care practices. The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations. We checked a sample of do not attempt resuscitation records for patients and found appropriate safeguards had been observed. The practice was also active within their Primary Care Network attending and contributing to meetings.

The practice worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Emergency equipment was available and maintained. Staff could recognise a deteriorating patient and knew of action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

There were systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment. We identified processes to monitor delays in referrals and the practice carried out audits to ensure ‘two week wait’ (2WW) cancer referrals had been booked with secondary care providers as a safety netting mechanism (2WW cancer referrals are urgent referrals used to investigate symptoms to detect cancer).

The practice detected and controlled potential risks in the care environment. For example, the practice had conducted an environmental risk assessment to ensure staff and people were safe and revised them annually or as more frequently in response to changes. Maintenance contracts were in placed to maintain the accuracy of equipment (calibration), scheduled safety checks were conducted on the fire alarm system, emergency lighting and equipment. They made sure equipment, facilities and technology supported the delivery of safe care. Contracts were in place to ensure the premises were maintained. Health and safety risk assessments and audits had been undertaken and risks identified had been addressed. There was a business continuity plan in place which was monitored and reviewed.

The practice made sure there were enough qualified, skilled and experienced staff, who received effective support, and development. They worked together well to provide safe care that met people’s individual needs. There were a range of clinical and non-clinical roles within the practice. We found training was up to date, learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence. However, not all staff records contained evidence of immunisation status or an application form. This was not in line with the provider’s recruitment policy. We alerted the provider to this and it was addressed immediately.

The practice assessed and managed the risk of infection. The practice had an Infection Prevention Control Audit, completed in November 2024, and the practice had been responsive and completed the relevant actions. The practice had a designated infection, prevention and control lead and all staff had had relevant training. We found all handwash dispensers were full and there were appropriate hand drying arrangements in place. We checked cleaning cupboards and found all cleaning items had appropriate processes in place to control substances hazardous to people’s health. We found the practice to be clean and tidy. However, there was no evidence of cleaning schedules completed by the external cleaning company. We alerted the provider to this, and to request these are provided by the external cleaning company.

The practice made sure medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened. Staff involved people in reviews of 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 training, were competency assessed on medicines optimisation, and felt confident managing the storage, administration and recording of medicines. However, prescription stationery was not being properly audited within the practice and needed to be reviewed to ensure it was managed appropriately and securely in line with national standards. From our remote clinical searches completed as part of this inspection, evidence showed clinical staff followed national protocols to ensure all medicines were prescribed safely, and ensured people received all recommended medicines reviews and monitoring. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines, vaccines, and controlled drugs. Waste medicines were recorded and disposed of appropriately including medicines returned by patients. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments. From our remote clinical searches completed, 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 risks received recommended monitoring. For example, all alerts received from the Medicines and Healthcare product Regulatory Agency (MHRA) (the national organisation responsible for ensuring medicines and medical devices are safe and appropriately dealt with) were managed and addressed in a timely manner.