Custom House 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.

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 fostered a proactive and positive safety culture. Staff listened actively to safety concerns, and incidents were investigated and reported appropriately. Lessons were learned and used to continuously identify and embed good practice.People felt supported in raising concerns and described staff as compassionate and understanding. Managers promoted openness, and staff felt confident speaking up when things went wrong. Clinical issues were discussed during team meetings, encouraging shared learning and continuous improvement.Safety was treated as a priority, supported by clear processes for reporting incidents, near misses, and safety events which included a significant event log and protocol. Complaints were systematically recorded and investigated, and when things went wrong, staff offered apologies and support.

The service worked collaboratively with individuals and healthcare partners to establish and maintain safe systems of care, where safety was actively managed and monitored. Efforts were made to ensure continuity of care, including during transitions between different services.

The latest national GP Patient Survey was conducted between December 2024 and April 2025, 89% of respondents reported being involved as much as they wanted to be in decisions about their care and treatment.

Leaders and staff reported that a designated team was responsible for managing referrals through the NHS e‑Referral Service. Staff monitored the system to ensure referrals to specialist services were accurately documented, included the correct information, and were processed in a timely way. Safety‑netting procedures were in place to ensure patients were appropriately followed up, and routine referrals were monitored to confirm whether patients still required specialist input or if their condition had deteriorated. A system was also in place to summarise patient records effectively.

One patient told us they had experienced a delay in receiving treatment due to an error in their referral form, which required amendment before the referral could proceed.

Monthly multidisciplinary team (MDT) meetings were held to review and improve outcomes for people with complex needs; alongside separate monthly MDT meetings focused on child and adult safeguarding.

The service demonstrated a commitment to taking immediate action to protect people from abuse and neglect, working collaboratively with partners to achieve this. A separate GP safeguarding lead for children and adults was in place, with both allocated protected time to review patients where safeguarding concerns had been identified.

Non-clinical staff were aware of the appropriate channels for reporting safeguarding concerns.

Staff worked with individuals to understand and manage risks holistically. They delivered care that was safe, supportive, and tailored to meet people’s needs, enabling them to engage in activities that mattered to them.

Emergency equipment was available and properly maintained. Staff were able to recognise when a patient’s condition was deteriorating and understood the appropriate actions to take. Patients were advised about risks related to their condition and were given guidance on what to do if their condition worsened.

The service had a comprehensive business continuity plan that addressed various risks, including fire, flooding, loss of computer or telephone systems, and staff shortages.

During our on-site assessment, we observed that the premises were clean, well- maintained, and conducive to safe care. Patients we spoke with confirmed that this was consistently their experience.The service had effective systems in place to monitor and comply with mandatory risk assessments, including fire safety and legionella testing, which helped ensure the safety of both patients and staff. Records confirmed that medical equipment was regularly maintained, calibrated, and tested.A business continuity plan was in place and was regularly reviewed and monitored to ensure the service remained prepared for potential disruptions.

The service ensured there were sufficient qualified, skilled, and experienced staff who received effective support, supervision, and development. Staff worked well together to deliver safe care that met people’s individual needs.A range of clinical and non-clinical roles were present within the service. Training was up to date, staff development and learning needs were appropriately managed, and individuals worked within their agreed areas of competence. Safe recruitment practices were followed.

There were systems in place to ensure there was effective oversight of advanced practitioners and non-medical prescribers. These included daily debriefs; regular teaching sessions; observation of consultations and records audits.

People we spoke with told us they found the premises clean and tidy and had no concerns relating to Infection Prevention and Control (IPC).The service had a designated IPC lead, and all staff had received relevant training. Cleaning schedules were in place and followed consistently. Risk assessments and audits were completed, with actions taken to mitigate identified risks.

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