Causeway Green 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 the service met people’s needs, and that staff treated people equally and without discrimination.

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.

The service 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 service. Managers encouraged staff to raise concerns when things went wrong. The practice had a significant events policy and the provider had processes for staff to report incidents, near misses and safety events, which was accessible to all staff members.

Staff we interviewed during the CQC assessment demonstrated clear awareness of the significant event process and confirmed that learning points were either shared across the service with the relevant staff involved or staff had access to minutes for learning.

There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Information reviewed demonstrated that people had opportunities to provide feedback, and they knew how to make a complaint. Lessons were learnt from individual complaints and shared with the practice team to improve the quality of care. Feedback and information were available in the practice and on their website.

The service 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 services.

Effective systems were in place for processing information relating to new people including the summarising of new records. The service worked with other providers to deliver shared care and when patients moved between services. We found clinicians made appropriate and timely referrals in line with protocols and up to date evidence-based guidance. This was supported by a system in place to ensure all patient information including laboratory test results and referrals were reviewed and actioned in a timely manner.

The provider told us that there were processes in place that were monitored and managed to keep people safe. For example, the provider was part of the Primary Care Network (PCN) and attended regular meetings with other agencies across the locality to share and discuss information relating to patient care and treatment.

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.

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 working in partnership with other organisations.

There was a safeguarding lead for children and adults, and all staff were aware of who to speak to if they identified a safeguarding concern. On reviewing a random sample of clinical records where safeguarding concerns had been recorded, we found some families were not linked on the clinical system to identify that there were safeguarding concerns within the family. This was discussed with the leadership team and alerts were added to the relevant records.

There were processes in place to follow up children and young people who were not brought to their appointments with the provider and for secondary care appointments.

Multi-disciplinary meetings were held to discuss vulnerable patients, including children on the safeguarding register, as well as those requiring palliative or end of life care.

There were systems in place for the renewal of DBS checks. Records we examined showed that all staff had a DBS check in place. 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.

The service 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.

All staff were trained in basic life support and staff could recognise a deteriorating patient. They knew of the action to take if they encountered a deteriorating or acutely unwell patient and had been given guidance on identifying such patients. Patients were advised on risks related to their condition and actions to take if their condition deteriorated. Emergency equipment was available and maintained.

Leaders told us that they worked with services locally to understand and manage risks. The practice also had registers in place to support those patients who were vulnerable or who had mobility or communication needs.

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

Health and safety related assessments and procedures to manage health and safety were in place. A range of health and safety risk assessments and fire risk assessments had been completed. Fire marshals had undertaken additional training for the role. Systems were in place for the regular checks of fire alarms, extinguishers and fire evacuation procedures with regular checks carried out around the building. The last fire drill had been completed in November 2025. Regular monitoring was in place to ensure guidelines were adhered to and all staff had been made aware of the appropriate procedures to follow.

Staff had been provided with training in health and safety related topics such as fire safety, infection control, basic life support and resuscitation training. Staff reported during discussions that they had no concerns regarding the arrangements in place to ensure health and safety.

The practice had completed assessments in place for the control of hazardous substances (COSHH). Evidence provided by the practice showed equipment was regularly calibrated and electrical items were PAT (portable appliance testing) tested. The latest calibration of equipment had been completed in December 2025.

There was a business continuity plan in place which was monitored and reviewed. Reception and administration staff who handled calls to the practice and arranged appointments with the clinical team were aware of potential red flag symptoms. Staff knew when to notify a GP or other clinicians with concerns about a patient who may be acutely unwell and/or deteriorating.

During our site visit we found the premises were well maintained. The provider detected and controlled potential risks in the environment. They made sure equipment, facilities and technology supported the delivery of safe care. Regular checks were carried out on the premises, facilities and the equipment provided. Contracts were in place to ensure the premises were clean and well maintained. Clear signage around the building supported people and staff in the event of an emergency evacuation.

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.

Evidence provided demonstrated systems were in place for the monitoring of staff, which included regular conversations as part of their clinical supervision. 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 had recruitment policies in place, and all staff had completed disclosure and barring checks. All newly employed staff had completed an induction to ensure they were competent in carrying out their role. We reviewed 4 personnel files and found appropriate checks such as previous employment record, immunisation status and proof of identity checks had been completed. Personnel folders were well organised and there was a systematic approach to ensure that personnel folders were managed appropriately.

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.

An infection control audit had been completed to identify potential risks and take appropriate action where required. At the time of the onsite assessment, the audit provided to us had been completed in August 2025, and the practice had achieved 100% overall.

The practice had a designated infection, prevention and control lead and all staff had completed training relevant to their role. Staff were aware of the systems and processes to follow to ensure clinical specimens were handled safely.

The practice had policies in place for infection, prevention and control which were accessible to staff and staff were aware of the action to take. For example, in the event of a sharps or contamination injury.

The service always made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They always involved people in planning, including when changes happened.

We carried out a random selection of clinical searches to review how patients’ medicines were monitored and if the appropriate care and treatment was being received. For example, we carried out a search to identify the number of patients with a potential missed diagnosis of diabetes. The review of HbA1c (HbA1c is a blood test that shows the average level of blood glucose) results demonstrated that all patient results had been appropriately reviewed and acted upon in line with clinical guidance. Where results indicated pre-diabetes or diabetes, the appropriate clinical action, advice, or follow-up was undertaken and documented. The practice’s systems for reviewing HbA1c results supported timely identification, management, and ongoing monitoring of patients, ensuring safe and effective care.

As part of the assessment, we reviewed the number of people who had been prescribed medicines to reduce the risk of blood clots forming called direct oral anticoagulants (DOACs), who had not received the appropriate monitoring in the past 10 months. The search identified 6 patients on these medicines who were overdue blood monitoring. We reviewed 5 clinical records and found 1 person had up to date renal monitoring and 4 people had been invited for blood monitoring.

We found the practice’s approach to medication reviews supported safe and effective prescribing, with clearly defined pathways to ensure the appropriate reviews were in place. We carried out a search to identify patients who had received a medication review in the past 3 months. The search identified 203 patients. We reviewed a random sample of 5 records and found thorough medicine reviews had been completed with clear documentation and evidence of safety, and ongoing monitoring where required.

The practice worked with the clinical pharmacists from the local Primary Care Network (PCN) to monitor people and the prescribing of medicines. All safety alerts were sent to the clinical pharmacists and leadership team to disseminate the information. The provider was able to demonstrate they had processes in place in relation to safety alerts issued by the Medicines and Healthcare products Regulatory Agency (MHRA). For example, we carried out a clinical search to identify women of childbearing age prescribed teratogenic drugs, medicines that has had the potential to increase the risk of birth defects. The clinical search identified potentially 19 patients on these types of medicine. We reviewed 3 records of patients on a particular medicine and found all 3 patients had not signed the annual risk acknowledgement form. Other searches carried out in relation to safety alerts showed good compliance in place. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.

The practice worked with the clinical pharmacists from the local Primary Care Network (PCN) to monitor people and the prescribing of medicines.

Emergency medicines, vaccines and medical equipment had clear monitoring processes in place. There were appropriate arrangements in place for the management of vaccines and for maintaining the cold chain. We saw fridge temperatures were routinely monitored and vaccines reviewed at random were in date and stored appropriately. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments.

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. Staff managed prescription stationery appropriately and securely. Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. Prescribing data reviewed as part of our assessment confirmed this. For example, the number of antimicrobials issued by the provider was lower than the local and national averages.