Dr Thusitha Gooneratne

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 staff protected people from avoidable harm and made sure care was delivered from environments that were clean and well maintained. At our last assessment, we rated this key question as good. At this assessment, the rating remains the same.
The service was in breach of legal regulation in relation to regulation 17 (good governance) due to weaknesses in how the service acted on information about risk, in oversight of policies and in documentation. We saw evidence that the service had identified these and were working to improve. We have asked the provider for an action plan.
 

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

The service had recently employed new staff who had identified weaknesses in how the service managed potential risks in the care environment. Actions identified on health and safety risk assessments completed in 2024 had not been taken. New assessments had been completed shortly before this assessment was announced, with the reports received just as the assessment took place. Shortly after the assessment the service sent us an action plan to address the issues identified on the health and safety risk assessments.
Equipment, facilities and technology supported the delivery of safe care. The service had contracts to ensure the premises was maintained. The service had a business continuity plan which was regularly reviewed and outlined how the service should continue to operate in the event of a disruption.
 

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.
The service employed a range of clinical and non-clinical roles, which included GPs, nurses and pharmacists. Leaders ensured staff were up to date with their training which the service had deemed mandatory and operated within their agreed areas of competence. The service followed safe recruitment procedures when employing staff. This included identity checks, review of qualifications, obtaining of professional references and a criminal records check for staff required by legislation. However, they did not have processes for considering the physical and mental health of an appointee in line with the requirements of the role.
 

The service had recently appointed a new lead member of staff for infection prevention and control, who had identified weaknesses in how the service assessed and managed the risk of infection. An infection prevention and control audit had been completed recently, but there had been a delay in completing the identified actions. Staff told us about previous audits of infection prevention and control, but the available evidence was incomplete. Controls to reduce the risk of legionella were not effective.
The service had cleaning schedules available, which outlined how staff should clean the building and its equipment. The service’s infection prevention and control lead was putting in place monitoring to maintain oversight of cleaning arrangements. During our onsite visit, the service's premises and a sample of equipment reviewed was noted to be visibly clean but there were some areas of damage to walls in clinical rooms. The service did not have information on staff immunity in line with national guidelines. The service had put in place an action plan to address the areas of weakness identified. Staff had completed relevant training in infection prevention and control.
 

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.