Blake 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

We looked for evidence that people were protected from abuse and avoidable harm.

We assessed all quality statements in the safe key question. At our last assessment we rated this key question as requires improvement. At this assessment the rating remained the same.

Leaders were working to embed a culture of openness and collaboration, but it was not adequate or consistent. Staff did not always have the right skills and experience and were unclear with their role and responsibility. The service did not always ensure staff received the appropriate level of supervision. Staff were encouraged to raise concerns and share ideas of improvement. However, actions to learn and improve were not always taken when ideas were presented to do so.

This service scored 47 (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 process for identifying, reporting and managing significant safety events and learning from these events are discussed in meetings. However, the policy regarding significant safety events did not contain up to date information in regard to the service's reporting to external agencies, such as Learning from Patient Safety Events (LfPSE).

The complaints log was not always kept up to date and contained numerous errors. The importance of maintaining a complaint log reduces the risk of errors and enables the service to recognise trends and promote a learning culture within the service.

However, staff were aware of the process to report a significant event.

The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care.

There was a clear process for recalling people with long-term conditions to ensure they are managed appropriately, this included system alerts. However, from our remote clinical searches, we saw people with long-term conditions were not always receiving reviews in line with national guidance. For example, our clinical searches identified 15 people as having a potential missed diagnosis of diabetes. Our GP SpA reviewed 4 of these records and found coding issues to diagnose diabetes, not responding to system alerts and lacking of a quality medicine review.

However, there was a system for processing letters from secondary care in a timely and safe manner to ensure individual clinical oversight. 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.

The service has a thorough guide to summarising new patient records (summarising patient records involves creating an electronic summary of key clinical information about each patient registered with the service).

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.

The service had a nominated safeguarding lead. Safeguarding concerns were regularly discussed as they were integrated into their monthly clinical governance meetings. Relevant staff attended or had the minutes shared with them and when needed action was taken. Meeting minutes confirmed this.

Safeguarding policies were known to staff, which included a process to follow if a child was not brought to appointments or if a vulnerable adult did not attend. Staff were appropriately trained in safeguarding procedures and had completed safeguarding training based on their role in accordance with national guidance.

Staff felt comfortable raising safeguarding concerns and knew who the designated safeguarding lead within the service was. There was a system which allowed the service to share oversight of at risk and vulnerable people with other services in the community by contributing to a list of vulnerable people. This was maintained centrally within the local primary care network (PCN). At the time of assessment, a system was not in place for checking with the local authority as to whether a child had been removed from this list. However, the service advised they will work toward a new system to ensure its efficiency and accuracy.

People were offered chaperones to attend appointments with them if they preferred. Posters about chaperones were displayed in the service’s waiting rooms. Staff had received appropriate training to act as chaperones. There was a mental capacity act (MCA) policy staff could access. It explained what the MCA is, record keeping and decisions covered by this act and the importance of recognising when to refer to the MCA. The MCA aims to ensure that individuals participate as fully as possible in all decisions relating to them.

The service worked with people to understand and manage risks by providing people with information and knowledge about their condition. 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, including emergency medicines, was available and maintained. All staff had completed training in sepsis awareness. Staff could recognise a deteriorating patient and knew how to escalate concerns.

The National GP Patient Survey from 2024 showed 91% of respondents were involved as much as they wanted to be in decisions about their care and treatment. This was in line with the local and national averages.

The service did not always detect and control potential risks in the care environment. The leaders of the service were not able to provide evidence to show they routinely perform and record health and safety risk assessments and audits.

The service had a Health and Safety policy that staff knew how to access. The policy references staff training, reasonable adjustments for staff who require them and general safety. Staff training did not show health and safety as part of their mandatory training, however, moving and handling was available to some of the staff.

We were sent a fire risk assessment following the onsite assessment which was dated February 2025, however, this did not detect the concerns found by CQC during assessment.

During our onsite visit, we noted a fire safety door was wedged open when it should have been closed. Oxygen cylinders were being kept in corridors and rooms without appropriate signage, meaning such cylinders were not being stored safely in line with national guidance, compromising the safety of people using the service in an emergency.

However, staff told us they had access to appropriate equipment to safely and effectively perform their role and there was a system in place to report and order defective equipment.

There was a business continuity plan in place to ensure service continuity in the event of an emergency.

The service 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.

There were a range of clinical and non-clinical roles within the service. However, they did not always make sure staff received effective support, supervision and development.

Systems were in place to alert staff that training was due. However, there was no oversight of this to ensure completion in a timely manner or that staff were appropriately enrolled in training relevant to their role. We were sent a document which showed not all staff were appropriately enrolled in training. For example, not all clinicians were enrolled in consent, IPC, sepsis awareness or safeguarding children. Other staff were not fully enrolled in standard mandatory training relevant to their roles. Such training included IPC, monitoring and maintaining cold chain (vaccine fridges) or basic life support. Training on supporting people with a learning disability and autism, was also not always accessible, and where available, it was often incomplete. Some staff had been overdue since 2024. The Health and Social care Act 2022 is the legislation that mandates training on learning disability and autism for registered health and social care providers and their staff.

Staff appraisals were noted as having been completed a week before our onsite visit. However, prior to this, some staff told us they had not received appraisals or supervision since joining the service, and some had been employed for several years. As part of the appraisal process, staff were asked to complete a form for their line manager to review with them in a meeting. Evidence showed these forms were not acknowledged by the line manager, and there were no records of discussions.

The service did not have a policy outlining clear expectations for clinical supervision, and there was no evidence that clinical supervision was being carried out.

However, the service had safe recruitment processes in place. Staff had a Disclosure and Barring Service (DBS) check relevant for their role. Staff had access to a handbook which provided them with information about working for the service. Such as dress code, sickness and absence and what support is available in the event of a grievance.

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly. The service did not have a designated infection prevention and control lead.

The service were not adhering to their own infection prevention and control (IPC) policy, which stated the practice nurse was the IPC lead. However, the practice nurse had not received sufficient training and support to ensure they had relevant knowledge to undertake this role. Risk assessments and audits relating to IPC were not being completed. IPC checklists were being completed but not consistently. An IPC checklist is a tool used routinely to check PPE, cleaning schedules, hand hygiene etc. and IPC audits will formally review processes that evaluate overall compliance IPC policy and national standards.

The service consistently maintained immunisation records for clinical staff but did not collect or store this information for non-clinical staff. There was IPC training available for all staff, although not all staff had completed this.

However, a cleaning schedule for the service was in place and followed. We observed the premises to be clean and tidy throughout our on-site visit.

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

Improvements had been made to some aspects of dispensary management since our previous inspection. For example, competency checks had been introduced to make sure dispensary staff were managing medicines safely.

There were suitable arrangements for ordering, storing and disposing of medicines, including those needing cold storage and controlled drugs Including regular controlled drugs audits and the recording of the full maximum and minimum temperature range in the dispensary refrigerator. However, these were not being recorded in line with the frequency recommended in the service’s standard operating procedure (SOP). We were told this would be addressed promptly, and updated procedures were put in place following our onsite visit which we saw sight of.

The dispensary was overseen by the leaders of the service. SOPs were kept under review and signed by dispensary staff. However, after speaking with staff, and reviewing evidence onsite, these were not always followed in full. For example, the service offered delivery to 2 local collection points for people who could not collect their medicines. Risks were assessed, people signed an agreement form to use this service, and suitable records were kept and procedures in place. Some medicines were prepared in blister packs, and there were safe systems in place for managing this. However, although staff were aware of the unsuitability of some medicines to be dispensed into these packs, the SOP in place did not include details of these risks or provide information for staff on how to check this. An updated SOP was put in place following our onsite visit to address this issue.

However, there were suitable systems to report incidents or errors. Medicine alerts and recalls were received and acted upon if relevant. Updated processes were put in place following our onsite visit to address this issue. Prescription stationery was securely stored and tracked by dispensary staff.