Lakenheath 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 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.

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.

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

The service had contracts to ensure the premises were maintained, which included for example, fire, electrical and water safety. Staff and leaders completed health and safety risk assessments and undertook audits to ensure they had identified and addressed all risks.Staff we spoke with were satisfied with the health and safety and fire arrangements in place. They had access to suitable equipment and technology to undertake their role. 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 staff in a range of clinical and non-clinical roles. Leaders were in the process of developing role specific induction plans. Evidence showed that a role-specific induction plan had been developed and completed for a newly appointed receptionist. Leaders ensured staff were up to date with training which the service had deemed mandatory and operated within their agreed areas of competence. Staff we spoke with were satisfied with the training and support they received. Arrangements were in place for the oversight of staff working in extended clinical roles, which included those who prescribed medicines. The paramedic received regular supervision and review of their practice by a GP, which was coded on the system.

The service followed safe recruitment procedures when employing staff, which was in line with national legislation. This included identity checks, review of qualifications, obtaining of professional references and Disclosure and Barring Service (DBS) checks. Checks of the professional registration of clinical staff were made at recruitment. However, there was no system in place to verify professional registration on an ongoing basis. Following the site visit the provider confirmed ongoing checks would be repeated at annual appraisals.

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 available, which outlined how staff should clean the building and its equipment. The service demonstrated how these were monitored to maintain oversight of cleaning arrangements. Staff we spoke with were aware of the infection prevention and control (IPC) arrangements in place. Our review of a sample of staff records confirmed that staff had completed IPC training. Leaders had requested IPC lead training for 3 clinicians and were waiting for this to be confirmed.

During our onsite visit, the service's premises and a sample of equipment reviewed was noted to be visibly clean. The service’s IPC leads conducted regular checks to ensure compliance and took action where necessary to mitigate any identified risks. We reviewed the most recent IPC audit and found actions identified had been completed or a plan was in place for them to be completed. For example, flooring in 1 of the treatment rooms had been improved. Appropriate arrangements were in place to manage clinical waste.

We reviewed a sample of staff immunisation records, and the service could evidence information relating to the immunisation status of staff. However, the provider acknowledged arrangements for the oversight of staff immunisations could be strengthened and confirmed they would act on this.

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