Lansdowne 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.

The service had contracts to ensure the premises was maintained. 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.

Portable appliance testing and equipment calibration were carried out regularly and monitored to ensure they remained up to date. Risks, including those related to fire, hot water systems and legionella, had been assessed and were appropriately managed. The service had a fire evacuation plan and policy, and relevant staff had completed fire warden training. The service also undertook routine safety checks of the fire alarm system, emergency lighting and associated equipment.

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 advanced care practitioners. Leaders ensured staff were up to date with their training which the service had deemed mandatory and operated within their agreed areas of competence. The service supported continuous professional development through regular training opportunities shared through staff newsletters and discussions during appraisals. Staff were undertaking a range of professional development activities, including specialist clinical training, such as diabetes, contraceptive coil fitting, menopause and dermatology.

The service followed safe recruitment procedures when employing staff, which were in line with national legislation. A review of 3 staff files confirmed appropriate recruitment checks had been completed, and records were maintained accurately. This included identity checks, review of qualifications, obtaining of professional references and a criminal records check. Staff received a structured induction tailored to their specific roles and responsibilities and included time for shadowing colleagues and meeting with leaders.

Informal clinical supervision was available to non-medical prescribers through case-based discussions and supervisory observations; however, this was not formally documented. The service subsequently provided a revised clinical supervision policy outlining arrangements for regular, documented supervision, supported by evidence of formal processes such as audits and reviews of clinical notes and prescribing.

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 a designated infection prevention and control lead (IPC), and staff were aware of who this was and how to escalate any concerns. All staff had completed relevant IPC training as part of their mandatory training programme. Personal protective equipment (PPE) was appropriately stocked and accessible, and clinical equipment was maintained in a clean condition.

The service had cleaning schedules available, which outlined how 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 and a sample of equipment reviewed was visibly clean. The service’s IPC lead conducted regular risk assessments and audits to ensure compliance and took action where necessary to mitigate any identified risks. For example, there was a risk assessment for the use of carpets in communal areas and parts of the consultation rooms, with regular cleaning arrangements in place to mitigate risk of cross-contamination.

Staff received training on the safe handling of specimens, and spillage kits were available when required. Cleaning materials were managed in line with processes to control substances hazardous to health. The service had established arrangements for the management of clinical waste, with appropriate segregation and disposal in line with current standards.

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