The Lakeside 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 inspection, we rated this key question as good. At this assessment, the rating has changed to inadequate.

The provider did not have an effective learning culture. Incidents were not investigated thoroughly to identify root causes, support learning, and prevent recurrence. Staffing was not managed effectively to ensure there were enough competent, trained, and experienced staff. Managers failed to ensure staff completed mandatory training in a timely manner. Administrative systems were ineffective and did not support the safe delivery of care. The premises and environment did not adequately support infection prevention and control, and fire safety and broader health and safety arrangements were insufficient.

This service scored 31 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider was unable to demonstrate a positive learning culture that promoted openness, reflection and continuous improvement. Staff had raised concerns relating to patient safety, safeguarding and chaperoning arrangements that were not explored, investigated or used as opportunities for learning and improvement.

Significant incidents were not routinely or consistently documented, or discussed with all staff to promote an open and transparent learning environment. There was limited evidence that lessons learned from concerns, incidents, complaints, and patient feedback were shared with staff or embedded within practice. Arrangements to communicate learning across the organisation were ineffective and did not support service improvement.

Feedback and complaints were collected and responded to, but the provider could not demonstrate that themes and trends were routinely analysed, translated into action plans or used to achieve sustained improvements.

Overall, leaders could not provide assurance that learning was embedded across the service or that information from concerns, incidents, and feedback was consistently used to improve the quality and safety of care.

Systems and processes were in place to support safe systems, pathways and transitions; however, these were not effective. The provider could not demonstrate that information was always shared appropriately to support the safe transfer of patients between services or that referrals were consistently managed and followed up in a timely manner. Although processes existed to monitor referrals, these were not applied consistently, increasing the risk that delays or gaps in care would not be identified promptly.The provider worked with other health and social care organisations to support patient care; however, there was limited assurance that communication and information sharing arrangements were consistently effective. We found little evidence that patient pathways were routinely reviewed to identify risks, monitor outcomes or drive improvements where concerns had been identified.Oversight of systems, pathways and transitions were ineffective. Leaders had not routinely monitored the effectiveness of these processes or used available information to identify themes, address risks and improve the coordination of care. Although we did not identify evidence of widespread harm, the provider could not demonstrate that systems consistently supported safe transitions and continuity of care.

Systems and processes to safeguard children and vulnerable adults were in place; however, they were not consistently effective. The provider could not demonstrate that safeguarding arrangements were implemented in line with national guidance or that all staff understood and fulfilled their safeguarding responsibilities. Not all staff had received safeguarding training appropriate to their role, and leaders could not provide assurance that safeguarding concerns were consistently recognised, recorded, escalated, and acted on appropriately, as there was insufficient documented evidence to demonstrate this. Safeguarding meetings were not consistently attended, and safeguarding was not routinely discussed with the wider practice team, limiting opportunities to share information, review risk and promote learning. Safeguarding policies and procedures were available, however, governance arrangements to monitor compliance and ensure their effective implementation were not consistently followed. We did not see evidence that safeguarding activity was routinely reviewed to identify themes, monitor trends or share learning to improve practice. The provider had not established effective failsafe systems to oversee safeguarding activity and could not provide assurance that people were consistently protected from the risk of abuse or neglect.

People were actively involved in identifying and managing risks associated with their health, care and treatment. Clinicians worked collaboratively with patients to discuss risks, benefits, and treatment options, enabling them to make informed decisions about their care. Records demonstrated that personalised care and treatment plans reflected people's individual needs, preferences and circumstances.Patients were provided with appropriate information and advice to help them understand and manage risks relating to their health and wellbeing. However, there was evidence where safety-netting advice was not always provided. Where people lacked capacity or required additional support, we were told that decisions were made in line with relevant legislation and involved carers or representatives where appropriate.Care plans and risk management arrangements were reviewed and updated to reflect changes in people's needs. The provider worked collaboratively with patients, carers and partner organisations to ensure risks were managed effectively across services and that continuity of care was maintained. However, governance systems did not provide assurance that people were consistently involved in decisions about managing risk and that shared decision-making was embedded within everyday practice.

The provider could not demonstrate that premises and equipment were safe or that effective systems were in place to identify, assess, and mitigate environmental risks. Governance arrangements relating to health and safety were ineffective, with significant failures to monitor, maintain, and act on identified risks. Leaders were unable to provide assurance that statutory requirements and national guidance relating to health and safety, fire safety, and premises management were being met.

The assessment identified multiple environmental hazards throughout the premises, including risks associated with the condition and maintenance of the building, unsafe storage of hazardous materials and equipment, and failures to ensure the premises were suitable and accessible for people using the service. Risks previously identified through external assessments and internal processes had not been addressed, demonstrating a failure to take timely action to reduce known risks.

There were significant concerns regarding fire safety and electrical safety. The provider was unable to demonstrate that remedial works identified through fire safety and electrical inspections had been completed, and systems to monitor ongoing compliance were ineffective. Required fire safety arrangements, including routine testing, record keeping, staff training, and the management of fire protection measures, were not implemented in accordance with legal requirements or the provider's own policy.

Equipment was not consistently maintained, serviced or stored safely. We found expired clinical equipment and medicines, inadequate storage arrangements, and insufficient assurance that equipment used in patient care remained safe and fit for purpose.

The provider could not demonstrate that sufficient systems were in place to ensure staff were appropriately recruited, trained, supported, and monitored to carry out their roles safely and effectively. Governance arrangements relating to the management of the workforce were ineffective, and leaders were unable to provide assurance that staff had the skills, knowledge and oversight necessary to deliver safe care.

Mandatory training was not effectively managed. At the time of the assessment, staff had not completed mandatory training appropriate to their roles and responsibilities. Although training had commenced after these concerns were identified, leaders acknowledged that protected time for learning had not been consistently provided and cited workload pressures and insufficient capacity as reasons why training had not been completed. This demonstrated that systems to ensure staff remained competent and up to date were ineffective.

Arrangements for staff supervision and support were inadequate. Leaders described an 'open door' approach to supervision; however, there was no documented evidence to demonstrate that staff received regular supervision, competency assessments or formal oversight. The provider could not demonstrate that staff performance, learning needs or professional development were routinely reviewed or that concerns were identified and addressed in a structured and consistent way.

Systems for communicating information and learning across the practice were ineffective. Staff did not consistently receive or act on key information, and leaders were unable to provide assurance that key messages, changes in practice or learning were understood and embedded. Opportunities for protected learning and development were not consistently implemented, limiting the provider's ability to promote continuous improvement.

Recruitment records contained significant gaps, and the provider was unable to produce recruitment documentation for GPs working within the practice. In addition, there were no effective systems to monitor the ongoing professional registration of clinical staff. Leaders relied on the assumption that clinicians maintained their own registration with the General Medical Council (GMC) or Nursing and Midwifery Council (NMC), rather than operating formal assurance processes.

The provider could not demonstrate that effective systems were in place to prevent and control the risk of infection. Infection prevention and control arrangements were not consistently implemented or monitored, and leaders were unable to provide assurance that the environment, equipment and clinical consumables were maintained in a manner that reduced the risk of cross-contamination.

The provider had systems in place to support medicines optimisation; however, these were not consistently effective. As part of the assessment, we conducted a series of remote clinical searches of patient records. These identified instances where patients had not received appropriate medicines monitoring or timely medication reviews in line with national guidance. As a result, leaders could not provide assurance that medicines optimisation processes were consistently effective across the practice.

We identified patients prescribed medicines where recommended monitoring had not been completed within the expected timescales. In addition, some patients with long-term conditions, including asthma, diabetes and hypothyroidism, had not received timely medication reviews or appropriate follow-up following abnormal clinical findings. The clinical searches also identified areas where prescribing practices and medication reviews could be improved to ensure they were in line with national guidance.

The provider could not demonstrate an effective process for reviewing and implementing MHRA medicines safety alerts or provide assurance that all relevant actions had been completed. Clinical searches were undertaken by the provider; however, findings had not always been translated into timely action to reduce risk and improve patient care.

We also identified concerns regarding the storage and management of medicines. Vaccine refrigerators were overstocked, expired vaccines and an out-of-date anaphylaxis kit were present, and the cold chain was not consistently managed in accordance with the provider's own policy. These findings reduced assurance that medicines requiring temperature-controlled storage were consistently managed safely.