Dr A M Cole & Partners, Lockswood 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. They made sure equipment, facilities and technology supported the delivery of safe care.

Staff and leaders completed health and safety risk assessments and undertook audits to ensure they had identified and addressed all risks. 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. Staff we spoke to understood the business continuity arrangements. The service had an ongoing maintenance and development programme, overseen by leaders with improvements they planned to make. For example, additional clinical rooms and larger staff areas.

The service had systems to help ensure premises and equipment were safe. For example, portable appliance testing (PAT) and equipment calibration had been completed and were routinely monitored. The service had implemented a fire risk assessment, evacuation plan and policy, and fire alarm testing was undertaken and recorded weekly. Scheduled safety checks were conducted on the fire alarm system, emergency lighting, and equipment in line with national guidelines.

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 a range of clinical and non-clinical roles, which included GPs, nurses, health care assistants, and pharmacists. Leaders had systems to ensure staff were up to date with their training which the service had deemed mandatory and operated within their agreed areas of competence. Upon our review of staff files, we found most staff had undertaken mandatory training in line with the service’s policy. Where leaders identified gaps in training they had plans in place to allow protected time for completion.

The service followed safe recruitment procedures when employing staff, which were in line with national legislation. This included identity checks, review of qualifications, obtaining of professional references and a Disclosure and Barring (DBS) check. Where administrative staff did not have a DBS check a risk assessment was undertaken and reviewed annually.

Following recruitment, staff completed an induction. Records reviewed in staff files demonstrated induction processes had been completed for both clinical and non-clinical staff. Development opportunities were available to staff to expand their responsibilities and undertake additional duties within their role.

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 systems and processes to support effective infection prevention and control (IPC) and the safe management of hazardous substances in line with service policy. Personal protective equipment (PPE) and spillage kits were readily available and appropriately stocked, and clinical equipment was clean and well maintained. During our site visit we observed the service had retained and stored Control of Substances Hazardous to Health (COSSH) risk assessments for most of the cleaning products stocked, alongside relevant Safety Data Sheets (SDS); however, we identified a small number of products where these were missing. Evidence provided demonstrated these were put in place following our visit.

The service had cleaning schedules available, which outlined how cleaning staff should clean the building and its equipment. The service demonstrated how these were monitored for completion to maintain oversight of cleaning arrangements. During our onsite visit, the service's premises was clean and well maintained. The service’s IPC lead conducted regular risk assessments and audits to ensure compliance and acted where necessary to mitigate any identified risks. Staff had completed relevant training in IPC and maintained the knowledge required to support safe care and treatment.

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