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 has changed to Good.

This service scored 72 (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. During staff meetings, the whole team discussed and learnt from clinical issues. We saw an example of this. 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. At the last inspection in May 2025, we found there was no failsafe mechanism in place to ensure no test results were missed. We found the practice had addressed this concern when we inspected in May 2026.

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. There was a lead for safeguarding. The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations. At the last inspection we found the practice was in the process of improving the way they worked with partners to ensure the information they held was accurate, up to date and coded correctly. At that time, the children’s safeguarding list was not accurate and up to date. At the inspection in May 2026, we found the practice had addressed these concerns and had embedded effective safeguarding procedures for children. However, we are aware of an ongoing concern relating to the communication of historical adult safeguarding concerns with the local linked care home. We will continue to monitor the findings of the local safeguarding team and how the practice responds to them.

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 of action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated. At the last inspection in May 2025, we found some concerns during our remote clinical searches related to the management of exacerbations of asthma and diabetic patients with very high HbA1c. At this inspection, our review of clinical records demonstrated they had improved processes in place and had addressed this concern.

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

Contracts 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 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. Since the last CQC inspection in May 2025, the practice had employed a salaried GP. This had improved clinical capacity and enabled more focus on clinical governance within the practice.

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.

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

At our May 2025 inspection, we identified concerns with the effectiveness of monitoring and review of people with long term conditions and medicines that can cause harm. During our analysis of clinical searches, at this inspection we found the practice had addressed the previously identified concerns, for example:

• The assessment of acute exacerbations of asthma had improved, however, the practice had not always routinely ensured a follow up appointment had taken place within an appropriate timescale. The practice had plans for this to become integrated into the procedure.
• There were no concerns with the monitoring of patients with diabetes who’s latest HbA1c (blood glucose levels) was >75mmol/l.
• All patients with hypothyroidism had received monitoring within the last 18 months.
• There were no concerns with the monitoring of patients prescribed direct oral anticoagulant (DOAC) medicines or methotrexate.
• Medicine reviews had improved, and were now detailed, comprehensive, and identified any concerns with monitoring.

Staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely. 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 followed protocols to ensure they prescribed all medicines safely, and ensured people received all recommended medicines reviews and monitoring. 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 effective systems to manage and respond to safety alerts and medicine recalls. Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring. 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 whilst higher than the national average, showed an ongoing downward trend. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.