Gardiner Crescent 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.

At our last assessment, we rated this key question as requires improvement. At this assessment, the rating remains the same.

The service was in breach of legal regulation in relation to Safe Care and Treatment

This service scored 62 (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.

At our inspection carried out in June/July 2023, we identified the system for managing significant events was not effective and the audit for managing patient safety and medicine alerts was not in place. At this assessment we found the practice had addressed most of these concerns, but some improvements were needed to ensure they continued to act upon historical alerts.

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. 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 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

There were systems in place for processing information relating to new patients. The service worked with other providers to deliver shared care and when patients moved between services. Referrals were managed in a timely way. Although arrangements were in place to check test results, there was no failsafe mechanism in place to ensure none were missed. We found one abnormal test result dating back to December 2024 which had not been actioned. We also found a small number of abnormal test results that had not been reviewed within 72 hours. The service addressed these shortly after the site visit.

The service was working with healthcare partners to improve their own understanding of what being safe meant to them and the best way to achieve that. When we checked, we found the children’s safeguarding list was not accurate and up to date. A new safeguarding lead had been identified and was working with partners to ensure the information they held was accurate, up to date and coded correctly. We signposted them to local experts to support them in continuing to develop their approach safely. However, we found 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 was in the process of improving the way they maintained the list of vulnerable people and acted on concerns working in partnership with other organisations.

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.

Emergency equipment was available and maintained. Staff could recognise a deteriorating patient and knew what action to take. Patients were mostly advised on risks related to their condition and actions to take if their condition deteriorated. However, we found some concerns during our remote clinical searches related to the management of exacerbations of asthma and diabetic patients with very high HbA1. Patients were not always having a timely comprehensive review of their condition and the medicines they were prescribed.

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

Arrangements 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 service had made improvements since the last assessment in ensuring there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. Since the last assessment in 2023, there was improved clinical capacity at senior nurse level, which had supported a greater spread of responsibilities within the practice and improved access for patients. However, we still had concerns about GP resources within the practice, which were low for the number of patients. From this assessment we saw this most evidenced within clinical governance, where there were gaps in the overview of clinical processes, checks and assurance processes. The provider had some opportunities they were pursuing to improve GP capacity, but these were still at an early stage.

At the last inspection on 27 June and 5 July 2023, we found the arrangements for locums recruited direct to the practice were not safe. Also, that the governance and oversight of staff training was not effective. At this assessment we found improvements had been made. Recruitment was undertaken in a safe way and staff training oversight had improved.

We found staff worked well together 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. Safe recruitment practices were followed.

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.

At the last inspection on 27 June and 5 July 2023, we found there were still some actions required following an infection prevention and control audit carried out by the local Integrated Care Board on behalf of the practice. This was mainly related to redecoration following remedial action that had been taken. At this assessment we found the redecoration had taken place and the practice had maintained the improvements made previously.

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.

There was some evidence staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely. However, some patients were overdue medicine reviews, and we found where they were carried out there were not always effective. All the medicine reviews we looked at had elements missing which impacted on their effectiveness and safety. There was a lack of detail included in the reviews. Not all medicines prescribed to the patients had been reviewed. There was no evidence to demonstrate the results of monitoring required to ensure safe prescribing was checked, and where monitoring had not taken place in line with best practice, this was not identified or addressed. Therefore, we were not assured patient safety was being appropriately assessed.

We were not assured that people knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms. We found there was a lack of processes established to ensure long term conditions and treatments were monitored regularly or robustly. Our search of the practice’s clinical system found that:

• Thirty patients living with asthma had received 2 or more courses of steroids in the last 12 months. The consultation records for people with asthma were of poor quality, the patient was not always assessed in person and there was little documentation to justify the issue of the steroids. Patients were not offered a steroid card, and patients were not always issued spacers with
• We identified 60 patients with diabetes who’s latest HbA1c (blood glucose levels) was >75mmol/l. We found patients were often overdue their medication review.
• Our clinical searches identified 2 patients with hypothyroidism were overdue their blood monitoring. However, both were significantly overdue monitoring and review and there was a lack of follow up to make sure these patients were monitored appropriately.
• We identified there was a lack of oversight of patient’s currently prescribed a direct oral anticoagulant (DOAC) medicine. Out of 106 patients currently prescribed a DOAC, 78 (73.6%) did not have creatinine clearance (CrCl) calculated in the last year. In addition, 15 out of the 106 patients had never had their CrCl calculated (14.2%). This put patients at a greater risk of bleeding or ineffective coagulation.
• The practice had not implemented the practice of recording the day of the week that patients should take Methotrexate, to reduce the risk of inadvertent overdose.
• Patients prescribed NSAIDs, anticoagulants or antiplatelets over the age of 75 were not protected from the risk of gastrointestinal irritation and bleeding. We found 43 out of 130 patients were not also being prescribed proton pump inhibitors to manage this risk.

Staff received regular training, were competency assessed on medicines optimisation, and felt confident managing the storage, administration and recording of medicines.

Medicines including controlled drugs were stored securely and at appropriate temperatures. 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. The provider had mostly effective systems to manage and respond to safety alerts and medicine recalls, but some improvements were needed to ensure they continued to act upon historical alerts.

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. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.