The Connaught Square 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.

At our last inspection in August 2018, we rated this key question as Good. At this assessment in December 2025, the rating has changed to Requires improvement.

This service scored 59 (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. 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. Lessons learned from complaints and significant events were shared with staff during staff meetings, and minutes of such meetings shared with all staff electronically. For example, the practice investigated an incident where an incorrect dosage of a patch medication was administered due to incomplete prescribing instructions. Following the investigation, the practice implemented appropriate actions, including reviewing the prescribing protocol. Clinical staff were reminded to ensure prescribing instructions clearly included the dose and frequency. Where there was any uncertainty, staff were advised to seek clarification from the prescribing specialist before issuing the prescription.

The practice worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They ensured that there was continuity of care and patient records were updated to reflect changing needs.

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 service shared concerns quickly and appropriately.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. The practice maintained a list of vulnerable people and acted on concerns and worked in partnership with other organisations such as the local safeguarding board.

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. The practice was equipped to respond to medical emergencies (including suspected sepsis) and staff were suitably trained in emergency procedures.

The practice had most of the appropriate emergency medicines in the stock. However, we noted the practice did not have dexamethasone (used to treat croup in children) and diclofenac (used to treat pain and inflammation) for intramuscular injection. The practice was unable to provide a documented risk assessment to explain why they decided not to stock these emergency medicines.

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.

The service did not always detect and control potential risks in the care environment. They did not always make sure relevant risk assessments were carried out by a qualified person in a timely manner.

An internal fire risk assessment had been carried out on 21 January 2025 however, it was not comprehensive, and there was no evidence to demonstrate that it had been completed by a suitably qualified person. We saw records showing the fire system was inspected regularly and that fire alarm checks were documented. The fire extinguishers were checked regularly, and the practice carried out regular fire drills.

A Legionella risk assessment was carried out by an external contractor in July 2015. According to the risk assessment document shared with us, a review was due in July 2016. However, on the day of the inspection the practice was unable to provide documentary evidence to demonstrate that a recent risk assessment had been carried out. We saw regular water temperature checks had been carried out. (Legionella is a term for a particular bacterium which can contaminate water systems in buildings).

There were contracts in place to ensure the premises were maintained. Health and safety risk assessments and audits had been undertaken and risks identified had been addressed.

A gas safety check was carried out on 29 September 2025.

The fixed electrical installation checks of the premises had been carried out on 12 September 2025.

There were records of equipment calibration which was carried out on 14 May 2025. Portable appliance testing was carried out on 6 June 2025.

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

Recruitment checks were not carried out in accordance with regulations prior to employment. For example, the 4 staff files we reviewed showed that references (satisfactory evidence of conduct in previous employment) had not been undertaken prior to employment for 2 staff. A contract was not available on the day of the assessment and interview notes were not kept in 2 staff files. Appropriate health checks (satisfactory information about any physical or mental health conditions) had not been undertaken prior to employment for all 4 staff members. A passport or evidence of the right to work in the UK was not kept in the file for 1 staff member. Confidentiality agreements were not signed by 2 staff members. Application forms or CVs were not kept in the files for 2 staff members.

Disclosure and Barring Service (DBS) checks were not always undertaken appropriate to the role where required. DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable. For example, we noted that DBS checks for a healthcare assistant (HCA) and most non-clinical staff were not available on the day of the assessment. The practice manager had received a ‘standard’ DBS check which was not appropriate to their role. All GPs had received enhanced DBS checks.

Staff who acted as chaperones were trained for the role. However, 2 staff who acted as chaperones had not received a Disclosure and Barring Service check (DBS check) and 1 staff had received a ‘basic’ Disclosure and Barring Service check (DBS check), which was not appropriate to their role and an appropriate risk assessment was not completed.

Shortly after the assessment, the practice informed us that they planned to process applications for DBS checks at the appropriate level.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development.

There were a range of clinical and non-clinical roles within the service. 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.

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

The practice had a designated infection, prevention and control lead and all staff had had relevant training. Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks.

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

Our clinical records searches showed that the practice did not always have an effective process for monitoring patients’ health in relation to the use of medicines. For example, we reviewed 5 patients with diabetes on a particular medicine, and found that all 5 patients had not been given advice on how to identify or respond to serious complications associated with its use, such as Fournier’s gangrene (bacterial infection of genital area) and diabetic ketoacidosis (a severe lack of insulin prevents the body from using sugar for energy and the body produces high levels of toxic acids called ketones).

We reviewed 5 patients who had been prescribed bisphosphonates (which are used to treat and prevent bone-related conditions such as osteoporosis) for over 5 years and found 2 patients had not received a bone density scan within the recommended period. However, 1 of these patients had not had a scan because they were currently bedbound due to a deterioration in their health. We also identified that 2 patients were overdue a medicines review.

Patients with asthma were offered an asthma management plan. However, we reviewed 5 patients with asthma who had been prescribed 2 or more courses of oral steroids in the last 12 months and found follow-up after 48 hours were not carried out for 3 patients after prescribing steroids.

We reviewed 4 patients who had used more than 12 Short-Acting Beta-2 Agonists (SABA) inhalers used for the treatment of asthma in the past 12 months. All 4 patients were found to overuse inhalers. High usage of SABA inhalers can indicate poor asthma control and an increased risk of exacerbations. (SABA inhalers are used to quickly relieve shortness of breath and wheezing in people with asthma). In addition, we found 1 patient was overdue asthma review.

A few days after the inspection, the practice submitted an action plan to address the clinical issues identified during the inspection. The practice assured us that these patients would be contacted and followed up.

The repeat prescription collection file at reception was not checked regularly, and we found some prescriptions that had remained uncollected since February 2025. However, a review of electronic records showed that most of these prescriptions had either been sent electronically or issued in error, meaning there was no risk to patient safety.

Staff managed prescription stationery appropriately and securely. We found that blank prescription boxes were stored securely in locked cabinets. We noted the serial numbers were recorded.

Medicines were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments.

Vaccines were appropriately stored in the fridges and fridge temperatures were monitored regularly. The practice had a secondary thermometer in the fridge used to store vaccines, which logged all the data and provided assurance that temperatures had stayed within the required range, as recommended in Public Health England guidance.

Staff had the appropriate authorisations to administer medicines (including Patient Group Directions and Patient Specific Directions).

The practice worked closely with the local Integrated Care Board (ICB) medicines management team regarding the safe prescribing of antibiotics within national guidance, and medicines optimisation.