Portsdown Group Practice Also known as Cosham Park House

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 Good. At this assessment, the rating remains the same. Facilities and equipment met the needs of people, were clean and well-maintained and any risks mitigated. There were enough staff with the right skills, qualifications and experience. Leaders made sure staff received training and regular appraisals to maintain high-quality care. Medicines were managed safely and people were involved in planning any changes to their medicines.

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 strong proactive and positive culture of safety, based on openness and complete honesty. They actively listened to concerns about safety and thoroughly investigated and reported safety events. Lessons were always learnt to continually identify and embed good practice. For example, significant events and incidents were a standing agenda item at partnership meetings and learning outcomes were shared with staff. There was an open culture of sharing significant events as learning experiences. The significant event policy was updated April 2025 and reflected current practice. People felt supported to raise concerns and were treated with compassion and understanding. Leaders encouraged staff to raise concerns when things went wrong. The service 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. The service carried out an annual analysis of their complaints to identify themes and trends, the service also analysed staff complaints as part of the annual review and discussed them in staff meetings to identify themes and learning. For example, a complaint regarding misdiagnosis was noted as a significant event, and the service used this to reflect and make improvements.

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 for processing information relating to new people. The service worked with other providers to deliver shared care and when people moved between services. Referrals and test results were managed in a timely way. Fortnightly workflow and summarising reports were created to proactively monitor backlogs and trends. The reports were also used to identify support needs, for example, staff training. Workflow audits assessed the task quality, volume and turnaround and these were regularly reviewed at governance meetings. The service had a referrals protocol in place and discharge summaries were processed via the pharmacy hub for medicines reconciliation and follow-up. This process aims to improve safety by reducing medicines errors and harm after hospital discharge by confirming the person's medicines list is accurate and up-to-date.

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. For example, new staff completed safeguarding training on induction, which was followed up at 3-month probation and refreshed annually. The service maintained a list of vulnerable people and acted on concerns working in partnership with other organisations. Staff were aware of who the designated safeguarding leads were for both adults and children and felt confident in escalating any concerns. Clinical staff members had chaperone responsibilities as part of their role. All staff members had completed Disclosure and Barring Service (DBS) checks to ensure they would be appropriate to undertake this role.

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. Staff could recognise signs of high-risk, red flag symptoms and the deterioration of people, this included both physical and mental deterioration. Staff were knowledgeable regarding the appropriate action to take, for example, a GP had supported receptionists to receive training on emergency symptoms including sepsis. The duty doctor was available throughout the day to support administrative staff should they needed to raise urgent clinical concerns.Emergency equipment was available at all sites however it was noted one of the emergency medicine trolleys was disorganised. There was no evidence of an audit of the emergency equipment at that site.There was no evidence of an audit of the emergency equipment at that site. We also noted an example where emergency equipment did not contain sharps boxes, eye protection and aprons. The service added these items immediately during the on-site visit. Staff could recognise signs of high-risk, red flag symptoms and the deterioration of people, this included both physical and mental deterioration. Staff were knowledgeable regarding the appropriate action to take, for example, a GP had supported receptionists to receive training on emergency symptoms including sepsis. The duty doctor was available throughout the day to support administrative staff should they needed to raise urgent clinical concerns.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Of the service’s 6 sites, we visited 5 sites as part of this inspection. The service had an estates management team who ensured systems and processes were in place to manage health and safety, such as legionella testing and servicing of water systems. The service used approved contractors and were undergoing renovation at one of the sites. The service had undertaken drone surveys to complete aerial reviews of the buildings focusing on the structural integrity of roofs and gutters. The findings showed where maintenance might be needed and provided an effective way to review the roofs and gutters of the surgeries. This modern approach allows for a safe and efficient assessment of hard-to-reach areas, identifying potential issues like water damage, missing tiles, or deterioration from a distance without the need for scaffolding or manual climbing. The service had also undertaken annual fire safety audits. Fire alarms and equipment were checked annually and evidence of fire drills including people using the service were evidenced. There had been a recent learning event which resulted in the service implementing larger vaccine fridges for continuity planning, which allowed for greater temporary storage should a fridge fail at one of the service’s sites. Equipment was tested and calibrated annually. Contracts were in place to ensure the premises were maintained. Health and safety risk assessments and audits had been undertaken, and any risks identified had been addressed. There was a business continuity plan in place which was last reviewed March 2025.

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. Safe recruitment practices were followed, however, some staff had not had their full vaccination results logged. For a member of staff who did not have a disclosure and barring check, no risk assessment was available as per the service’s own policy. The service responded and addressed these immediately during the inspection. There were a range of clinical and non-clinical roles within the practice. Training was up to date, learning needs and development of staff were managed appropriately, and staff were working within their agreed areas of competence. For example, inhouse training sessions were recorded for staff who could not attend. The inhouse staff training days included external speakers, who covered basic life support and updates on chronic obstructive pulmonary disease. There were systems and processes for monitoring training compliance to demonstrate staff were able to carry out their roles appropriately. The provider set a minimum completion percentage of mandatory training at 90%. At the time of the inspection, we noted the service’s mandatory training completion rate for all staff was 98.95%. Appraisals had been completed annually and new staff received probation reviews to monitor their performance.

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. Risk assessments and audits were in place and actions taken to mitigate risks, for example, legionella risk assessments and certificates were retained. The service had a designated infection prevention and control lead and all staff had completed relevant training. Waste, sharps, and clinical specimens were managed in line with national guidance to keep people safe. The service had undertaken an annual examination couch audit and as a result, had implemented a regular steam cleaning protocol to ensure equipment remained safe to use. During our onsite visits to branch locations, inspectors requested various types of evidence relating to cleaning practices and standards. It was observed at the Cosham branch that the cleaning cupboard was disorganised and untidy and staff present at these sites were unable to immediately provide the requested documentation, as all relevant evidence was held centrally rather than at individual branches.

As a result, cleaning schedules could not be promptly accessed to demonstrate compliance with national guidelines on cleaning standards. Despite this initial difficulty, it should be noted that the provider maintains an estates department, which subsequently supplied the necessary documentation. This included cleaning schedules from the cleaning company for each site, confirming that standards were being met as required.

The service always made sure medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened. Staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely. However, the service confirmed they had encountered some challenges in monitoring the medicines for people with no fixed abode. As a result, the service ensured people who approached the service faced no obstacles in receiving support and everyone had equal access to healthcare provision.

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 people. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments. The service 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. For example, the number of antimicrobials issued by the service was lower than local and national averages.