Goodheart 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 good. At this assessment, the rating remains the same. Although there were areas for improvement relating to recruitment, recording clinical supervision, identification of IPC risks, monitoring and recording medicines fridge temperatures, authorisation of PGDs and ensuring patients were aware of the risks of their prescribed medicines the provider took immediate action to address these areas.

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.

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. Managers encouraged staff to raise concerns when things went wrong. During staff meetings, the whole team discussed and learnt from clinical issues. 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. For example, the appointment booking system had been reviewed and changed in response to patient complaints and staff told us this had reduced complaints significantly.

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. New patients were offered new patient check if they had a long-term condition.

The service worked with other providers to deliver shared care and when patients moved between services.Wound care clinics were offered at the practice and in appointments provided by the primary care network (PCN) and Saturday clinics were available at multiple PCN sites to ensure ease of access for patients.

Referrals and test results were managed in a timely way. Systems were in place to prioritise urgent referrals and patients were advised to contact the practice if they had not received an appointment. Referral processes had been reviewed and improved to minimise the risk of delay following the practice having identified a slight delay to a referral being sent on. Although one GP kept a list of patients referred on the urgent pathway, there was no formal system to monitor if the patient had been seen, staff told us they would review this and put a system in place.

Staff had responsibility for specific administration tasks and were knowledgeable about their role. Staff were trained to complete all the administrative tasks to enable them to assist with workload in other areas when required.

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. The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations.

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. Information was available to staff and staff had received training in sepsis. Patients were advised on risks related to their condition and actions to take if their condition deteriorated. Palliative and deteriorating patients were given the direct telephone number for the reception manager and regular reviews were undertaken by surgery and PCN Paramedic.

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

The practice was in a shared building with other health services. The building was maintained by an external company and there was a permanent building manager on site for any immediate and necessary work to be carried out. Health and safety risk assessments and audits had been undertaken and risks identified had been addressed. A fire risk assessment was in place and had been reviewed. There was a business continuity plan in place which was monitored and reviewed. This was further reviewed and improved during the assessment to include actions in the case of flooding and adverse weather conditions.

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. However, recruitment procedures had not always been operated consistently, and competency checks, and clinical supervision was not recorded.

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. Staff were encouraged and supported to develop their careers, for example, one member of staff had been supported to undertake training to be a GP assistant. Staff were working within their agreed areas of competence and confirmed they were well supported and received annual appraisals. The practice was a teaching practice for GP registrars and medical students and debrief sessions were held after every clinic for registrars/ trainees. Clinical staff told us they had clinical meetings, and these were documented, and they worked closely with the lead GP. We did not see any records of clinical supervision and competency checks. The recently employed lead nurse told us they would be implementing formal clinical supervision and competency checks and had a template on which to record this.

We reviewed 3 recruitment files. DBS checks were carried out on staff and annual declarations for those staff not on the live DBS register had been completed. However, not all recruitment files were complete in that there was no proof of identity including a recent photograph for the lead nurse and there no evidence of a health check for the lead nurse and GP assistant. There was evidence of a new process in place for health checks in the recruitment file for a more recently appointed member of staff. There was evidence recruitment had been identified as an area for improvement in the practice improvement plan and a check list for the recruitment process and associated documents had been developed but not yet implemented. The practice manager told us after the assessment that they had had an electronic copy of the lead nurse passport for ID purposes and had now put a copy of this in the recruitment file.

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 (IPC) lead and all staff had received relevant training. Cleaning schedules were in place and followed and all areas were clean and tidy. Risk assessments and audits were completed, and actions had been taken to mitigate most risks. For example, damaged chairs had been identified in an external audit in 2024 and the action plan showed this as completed. However, we saw GP chairs in 2 consulting rooms which were damaged and therefore could not be effectively cleaned. The damaged GP chairs had not been identified in the most recent IPC audit of April 2025.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Medicines including controlled drugs were stored securely and at appropriate temperatures. However, the fridge used to store medicines had not had the temperature recorded daily on a consistent basis, for example, temperatures had not been recorded 6 times in February and March, 7 times in April, and 4 times in May 2025. Data loggers were provided in the fridge, and data was downloaded weekly and findings recorded. Data logger records showed fridge temperatures were within the recommended range apart from 2 spikes above 8 degrees centigrade for very short periods of time in March 2025, this had not been identified and recorded on the temperature record sheet. The practice implemented improvements immediately to minimise the risk of errors in future recordings. They also immediately referred the issues to NHS England. NHSE informed the practice and CQC that they were satisfied appropriate action had been taken by the practice to minimise risk.

Patient Group Directions (PGDs) are written instructions allowing health professionals to administer specified medicines to a specific group of patients without a specific prescription. These had been signed by the authoriser for staff deemed competent to administer these. However, some staff had signed these after the authoriser. The lead nurse took immediate action to address this.

Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines, vaccines, and controlled drugs. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments.

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 was mostly lower than local and national averages. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.

Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring. Findings from clinical searches showed generally good oversight of patients prescribed high risk medicines. However, we identified some areas for improvement. For example, for patients prescribed an immunosuppressant, the day the patient should take the medicine was not on the repeat prescription request template and there were 2 patients who required blood results to be followed up. Following the assessment the provider submitted an action plan which showed actions taken to address findings. Actions included contacting the patients on the medicine and ensuring day of administration was recorded, adding day of administration onto patients repeat prescribing template and liaising with the secondary care consultant to ensure the day to be taken was recorded on future correspondence. The two patients who required follow up regarding blood results had been reviewed and the information shared with all clinicians in a clinical meeting.

The provider mostly had effective systems to manage and respond to safety alerts and medicine recalls. The practice was supported with medicines alerts by the PCN who shared alerts with the practice and a PCN pharmacist assisted with searches and monitoring patients. However, we found areas for improvement for two prescribed medicines which had been subject of an alert as they may present risks for patients of childbearing age. For the 4 patients prescribed an anti-convulsant medicine there was good oversight of the requirements for prescribing and awareness of the annual risk acknowledgement form (ARAF) and pregnancy protection plan (PPP) which were in place. However, a second signature on these documents was required from secondary care. For 8 patients prescribed a different anticonvulsant medicine there was a lack of evidence of a face-to-face discussion with patients of child baring age and that ARAF and PPP had been completed regarding risks and the need for contraception. Following the assessment the provider submitted an action plan which showed actions taken to address findings relating to the two medicines. Actions included inviting patients for a face-to-face review and discussion about risk and writing to secondary care clinicians for ARAF and PPP dual signature.