Lee Road 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 inspection, we rated this key question as good. At this inspection, the rating remains the same.

We found the service had a good learning culture and people could raise concerns. Managers investigated incidents thoroughly. Facilities and equipment were clean and well-maintained. There were enough staff with the right skills, qualification, and experience. Patients did not always receive monitoring tests for their prescribed medicines.

This service scored 66 (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 had a proactive and positive culture of safety, based on openness and honesty. Themes had been identified and action had been taken to make improvements. Staff were able to describe the process for reporting significant events and managers encouraged staff to raise concerns when things went wrong. Staff were able to give examples of significant events and we saw evidence of shared learning from incidents. We found the provider to be open with patients when incidents had involved or impacted patients.

The service worked with people and healthcare partners to establish and maintain safe systems of care. There were systems in place for processing information relating to new patients. Referrals and test results were managed in a timely way.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. Staff knew how to raise safeguarding concerns and where to find information to support them to do this. The service worked with healthcare partners to share concerns.

The provider carried out staff checks at the time of recruitment and on an ongoing basis where appropriate. Disclosure and Barring Service (DBS) checks were undertaken where required (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable).

The practice maintained a list of vulnerable people and alerts were placed on the practice system to alert practice staff to children on the safeguarding register. However, there were no such alerts on the adults living in the same household as children on the safeguarding register. Following our site visit, the provider told us that alerts had been added to household members of all children on the safeguarding register.

The service worked with people to understand and manage risks. They provided care to meet people's needs that was safe, supportive, and enabled people to do the things that mattered to them. Staff could recognise a deteriorating patient and knew of action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

Health and safety risk assessments had been undertaken and risks identified had been addressed. There was a business continuity plan in place which was monitored and reviewed. The provider ensured equipment and facilities supported the delivery of safe care.

Emergency equipment was available and maintained. The practice did not hold a spare set of adult defibrillator pads or paediatric defibrillator pads. However, following our site visit, the provider sent evidence that both items had been purchased and were available for use in the practice.

The service made sure there were enough qualified, skilled, and experienced staff. They worked together to provide safe care that met people’s individual needs. We found training was up to date and safe recruitment processes were followed. We reviewed 5 staff files and found that 2 staff members had not had an appraisal in the last 12 months. The provider had identified that some members of staff were overdue an appraisal, we saw evidence that appraisals had been scheduled for these members of staff. Staff told us they could easily speak to GPs or leaders at the practice for guidance, however the processes for clinical supervision of non-medical staff were not always formal and regular. We discussed this with leaders at the practice. The provider told us they planned to conduct audits of consultation notes as part of the appraisal process.

The service assessed and managed the risk of infection. The practice had a designated infection, prevention, and control lead. Staff had completed relevant training. Risk assessments and audits were completed and action taken to mitigate risks. We observed some clinical rooms to have carpeted floors, the provider told us these would be removed at the next refurbishment of the practice.

We carried out remote clinical searches on the practice’s clinical system. We found people did not always receive all medicines reviews and monitoring.

We reviewed 5 patients prescribed a medicine to treat autoimmune conditions and found 2 patients were overdue monitoring tests. There was no evidence that monitoring was checked before prescribing for all 5 patients. The day of the week the medicine should be taken was not recorded for 4 patients.

We reviewed 5 medication reviews carried out and found these lacked detail. There was no documented evidence that all repeat medicines had been reviewed or that the reviewer had checked monitoring was up to date.

We reviewed 5 reviews of care plans for patients with dementia. Two of the reviews did not include documented evidence that the reviewer had discussed the patient’s current medical conditions or considered the patient’s wishes.

Following our feedback of these findings, the provider sent us evidence of an action plan of how these concerns would be addressed.

We found medicines held at the practice were stored securely and at the appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines.