Ilford Lane 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

We looked for evidence that staff protected people from avoidable harm and made sure care was delivered from environments that were clean and well maintained. At our last assessment, we rated this key question as good. At this assessment, the rating remains the same.

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.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

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

The practice provided care from premises that were well maintained, clean, and suitable for the population it served. The building was purpose-built with level access, accessible parking, and lift access, and reasonable adjustments were in place for physical and hidden disabilities. On the day of our visit, a daily cleanliness checklist was in use in every clinical room. Rooms not in use that day still carried the green sticker system confirming the room and equipment had been cleaned.

A fire risk assessment had identified minor actions which were all completed. Fire alarm testing, extinguisher servicing, and fire drills were observed, and a general health and safety risk assessment had been reviewed within the past year with no significant issues identified. A fire warden was in post with relevant training completed, including refresher training. A legionella risk assessment had identified remedial works in progress with NHS Property Services, the building's landlord.

Equipment and technology were well maintained, with portable appliance testing and calibration externally contracted annually and automatically rebooked. This was confirmed by an observed calibration log. Resuscitation equipment and oxygen were checked regularly in line with a documented schedule, with a risk assessment for emergency equipment confirmed in place. The building was secured by a layered key-code system.

Safety alerts relating to equipment and medicines were managed through a direct subscription to Medicines and Healthcare products Regulatory Agency alerts, logged with actions taken and discussed monthly. A business continuity plan, reviewed annually, formed part of a a comprehensive, dated policy register covering premises and safety matters.

However, there was no formal written log of actions from external audits or risk assessments. The leadership recognised the gap and produced written action log capturing fixes from external audits and risk assessments, addressing the lack of a documented audit trail.

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.

Recruitment records for the sample of five staff members we reviewed showed a robust, consistently applied process that ensured appropriate recruitment checks, such as references and professional registration, were carried out and documented. Disclosure and Barring Service checks were renewed at least every three years for clinical staff and tracked on a spreadsheet flagging expiry dates.

Training was managed through the Bluestream Academy platform, with automated renewal prompts and protected time allocated for completion. Learning Disability and Autism training was not evidenced in the training matrix at the time of assessment. The practice subsequently confirmed it had been booked for the salaried GP to complete. New GPs completed a structured induction, however, supervision during induction was not documented. The leadership acknowledged the gap and committed to introducing a document to record supervision going forward. Locum and agency staff had certificates, indemnity, and IT system competency verified before placement, with locums restricted from adding items to a patient's repeat prescribing template. Locums were sourced through an informal network of known colleagues rather than a formal agency and the same safety checks were applied.

The practice showed a clear staff development culture, with several staff having progressed from reception into clinical and management roles through defined pathways, and staffing levels with one lead GP, two salaried GPs, one nurse with a second developing, and one healthcare assistant were proportionate to demand.

Appraisals were completed and documented for all staff sampled. Day-to-day clinical supervision, while described consistently as happening regularly through informal daily contact, was not consistently documented. This was confirmed across interviews and in four of the five staff files reviewed. Reception and admin supervision, was recorded through minuted one-to-one meetings. A supervision policy was in place and the leadership team accepted the need for supervision documentation.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Infection prevention and control was led by the practice nurse, who staff knew how to contact and who reviewed premises, equipment, and procedures regularly. A dated infection prevention and control policy and handbook were in place, alongside logged, dated policies covering waste management, clinical waste risk, sharps containers, and staff occupational health and immunisation. The IPC lead had not completed role-specific training, however, correspondence predating the inspection showed this had been arranged.

Audits were carried out and acted on. For example, a monthly, room-by-room infection control audit with findings and an action plan filed centrally, a random hand hygiene and sharps bin spot-checks, with no issues identified in the most recent hand hygiene analysis. On the day of our visit, a daily cleanliness checklist was in use in every clinical room. Two-cycle infection control audits were observed during the assessment.

Clinical areas were clean and well maintained, with wipeable surfaces, regularly changed curtains, adequate personal protective equipment, waste bins, handwashing facilities and alcohol hand rub in every room. Equipment was either single-use or cleaned between patients. Sharps bins in every clinical room were correctly assembled, signed, dated, and not overfilled. Waste, sharps, and specimen handling followed a described and observed process consistent with national guidance.

All staff had completed infection prevention and control training to an appropriate level, and staff vaccination and immunisation status was tracked on a spreadsheet with expiry alerts. Risk assessments were used where a staff member's status was outstanding, and declinations were appropriately documented. Staff understood how to report a notifiable disease, with doctors holding direct links to the reporting system and the nurse escalating to the lead GP where needed.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.