Tudor Lodge 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 good.

The practice had an effective learning culture and people could raise concerns. Managers investigated incidents thoroughly. People were protected and kept safe. Staff understood and managed risks. The facilities and equipment met the needs of people, were clean and well-maintained and any risks mitigated. There were enough staff with the right skills, qualifications and experience. Managers made sure staff received training and access to clinical supervision to maintain high-quality care. Staff managed medicines well and involved people in planning any changes.

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 practice 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.

Safety was a priority for everyone and was supported by those with clear roles and responsibilities for safety. People felt supported and encouraged to raise concerns and felt staff treated them with compassion and understanding. Representatives from the Patient Participation Group (PPG) felt the provider took concerns seriously and proactively made improvements to the service. Staff felt there was an open culture and leaders encouraged staff to raise concerns when things went wrong. 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 was identified and was used to improve care and treatment. The practice had received a low number of formal complaints they had recorded and investigated (8 for the 2024-25 and 4 so far for 2025-26). There was a process in place to proactively request feedback from people when after they requested an appointment, the practice responded to feedback in a timely manner which resolved issues quickly. This had reduced the amount of formal complaints received. Learning from incidents and complaints resulted in changes that improved care for others.

The practice 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 people joining the practice. Referrals and test results were managed in a timely way. The practice employed a regular locum GP to review incoming documents on a daily basis to ensure they were promptly addressed. Clinical correspondence was directed to the person’s named GP for them to review, which supported continuity of care for people.

The nursing team included staff that had specialist knowledge and training to appropriately support people. For example, the practice employed a frailty nurse supported people that lived in local care homes by working with partners organisations in a local care home hub, as well as GPs at the practice. This supported these patients with a coordinated approach to ensure people were kept safe and inappropriate hospital admissions were prevented. The frailty nurse also linked in with the wider network of older people services in the locality to improve people’s care journey and ensure smooth transitions between services.

The practice 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 practice shared concerns quickly and appropriately.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures and knew who the safeguarding lead was. The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations.

The practice received minutes from a local safeguarding meeting so could be alerted to any vulnerable people that were discussed, who were registered at the practice. The safeguarding lead was planning to implement a formal monthly safeguarding meeting to discuss people at risk of harm and to attend the local safeguarding meeting to improve oversight of vulnerable people. Although the practice did not hold a regular dedicated safeguarding meeting, safeguarding was a standing agenda item at the weekly clinical meetings to ensure concerns were addressed in a timely manner.

The practice 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. Systems were in place to ensure staff could recognise a deteriorating patient and knew what action to take. For example, people with immuno-suppression (a weakened immune system) had digital flags applied to their records so when they requested an appointment, this was clearly visible and potentially expedited their request to prevent rapid deterioration.Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

As part of our inspection, a number of set clinical record searches were undertaken remotely by a CQC GP specialist advisor. These searches were visible to the practice. Our searches identified 929 people on the asthma register of which, 5 people had been prescribed 2 or more courses of steroids due to an exacerbation of asthma. We reviewed 5 of these patient records and found people were well monitored, followed up appropriately, had their regular treatment had been stepped up or adjusted and been issued with a steroid card.

People were able to use a machine in an area behind reception to independently take their height, weight and blood pressure. This machine linked to the patient’s record and automatically updated it with the results. This meant people could attend the practice at a suitable time for them to record these measurements and did not have to take up an appointment slot.

The practice detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Clear signage was on display around the building to support people in an emergency. Contracts were in place to ensure the premises were maintained. Health and safety risk assessments and audits had been undertaken and risks identified had been addressed. The practice made reasonable adjustments when people found it hard to access services such as having step-free access and ground floor level rooms.

A business continuity plan contained details of what to do in the event of an emergency such as a power cut or extreme weather affecting the delivery of the service. This was monitored and regularly reviewed. Staff had completed appropriate training in areas such as health and safety, and information governance.

The practice made sure there were enough qualified, skilled and experienced staff who told us they received thorough support, supervision and strong development opportunities. They worked together well to provide safe care that met people’s individual needs.

There were appropriate staffing levels with a skill mix made up of a range of clinical and non-clinical roles. We found training was up to date and the learning needs and development of staff was managed appropriately. Staff had either completed mandatory learning disability and autism training or were booked on the next available date.

Although staff were working within their competencies and had access to clinical supervision, there was no formal process to evidence this was the case. The practice took immediate action to address this and implemented a new competency review process.

We viewed a sample of staff files and although we saw safe recruitment practices were being followed. Professional registrations were checked upon employment but the practice had not routinely checked and recorded that staff registrations were current. The practice immediately addressed this and gained evidence of the up-to-date professional registrations. They told us they were implementing a new monthly process to review professional registrations to ensure they were up-to-date.

The practice assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. Cleaning schedules were in place and followed. During the onsite visit, we found the premises was visibly clean. Sharps bins, for used needles were appropriately stored and managed. Personal Protective Equipment (PPE) was available to staff.

The practice had a designated infection, prevention and control lead and all staff had had relevant training. Risk assessments and audits were completed, and actions taken to mitigate risks.

There was a process to record staff vaccinations in line with national guidance. The practice had viewed evidence staff had received appropriate vaccinations.

The practice made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

Staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely. People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms. Staff received regular training and felt confident managing the storage, administration and recording of medicines. Staff managed prescription stationery appropriately and securely. Staff followed protocols to ensure they prescribed all medicines safely, and ensured people received all recommended medicines reviews and monitoring.

We saw medicines were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines, vaccines, and controlled drugs. Waste medicines were recorded and disposed of appropriately including medicines returned by patients. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments.

The provider had effective systems to manage and respond to safety alerts and medicine recalls. Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring and advice.

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

We reviewed a sample of Patient Group Directions (PGDs) (a written instruction for the supply and/or administration of a named licensed medicine for a defined clinical condition by named registered health care professionals without them having to see a prescriber) and Patient Specific Directions (a written instruction from a doctor or other independent prescriber for a medicine to be supplied or administered to a named patient). We found a minor error with the completion of PGDs which the practice addressed immediately.