Ramanathan 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 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.

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.

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 did not always identify and effectively manage potential risks within the care environment. Equipment, facilities and technology were not consistently managed in a way that supported the safe delivery of care.

The provider had arrangements in place to maintain the premises, including maintenance contracts, health and safety risk assessments and regular audits undertaken by staff and leaders. However, inspection findings demonstrated that risks were not always identified, monitored or appropriately addressed.

At the time of inspection, a fire risk assessment had not been completed to identify and manage fire safety risks. We found there were no fire alarms installed and no evidence of documented fire drills, although smoke alarms were present throughout the premises. Following the inspection, the provider took immediate action by commissioning an external fire risk assessment, conducting and recording a fire drill and developing an action plan to address identified concerns and support sustained improvement.

During the inspection, blinds within clinical and patient areas were found to have unsecured pull cords, creating a potential ligature risk for people who may be vulnerable. The provider responded promptly and provided evidence that remedial action had been taken to remove the immediate risk.

The service's Infection Prevention and Control (IPC) Lead conducted regular audits to monitor compliance. However, action was not always taken to address identified risks. For example, the cleaners' cupboard was not locked and could be accessed by members of the public. Following the inspection, the provider took action and provided assurances that locks had been fitted and the cleaning cupboard had been decluttered and secured.

We also identified concerns regarding the security of prescription stationery. Prescription stationery was observed unsecured in a printer within the nurse's room, presenting a risk of unauthorised access and misuse. The provider took immediate action to address this issue and mitigate the associated risks.

Whilst concerns relating to fire safety, environmental risks, prescription security and infection prevention and control were identified, the provider responded positively and promptly to the concerns identified, further assurance is required to demonstrate that improvements have been embedded and sustained in practice.

The service had a business continuity plan in place which outlined how services would continue to operate in the event of disruption. The plan was accessible to staff electronically and was subject to regular review.

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 GP Partners, a practice nurse and a phlebotomist. 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, which were in line with national legislation. This included identity checks, review of qualifications, obtaining of professional references and Disclosure and Barring Service (DBS) checks for all staff.

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 service had cleaning schedules in place which outlined how staff should clean the premises and equipment. The service demonstrated how completion of these schedules was monitored to maintain oversight of cleaning arrangements. During our onsite visit, the premises and a sample of equipment reviewed were visibly clean.

Staff had completed relevant infection prevention and control training.

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