Prince Avenue Surgery Also known as Dr Sooriakumaran & Dr Santhakumar

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

At our last assessment in 2015, we rated this key question as Good. At this assessment, the rating remains the same. We looked for evidence that people were protected from abuse and avoidable harm.

There was a culture of learning from safety events and when things went wrong, managers investigated incidents thoroughly. Recruitment checks were generally carried out in accordance with regulations and new staff received an informal and formal induction to their work. There were enough staff with the right skills, qualifications and experience and staff received continuous, ongoing feedback. Staff managed medicines well and involved people in planning any changes. Our review of the clinical system found that patient’s medication and conditions were generally well managed.

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 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. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Managers encouraged staff to raise concerns when things went wrong. The provider had processes for staff to report incidents, near misses and safety events. During staff meetings, the whole team discussed and learnt from clinical issues. Staff felt there was an open culture, and that safety was a top priority. The provider took concerns seriously and proactively made improvements to the service. Learning from incidents and complaints resulted in changes that improved care for others. Lessons were learnt to continually identify and embed good practice.

The service 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 patients. A system was in place to summarise patient records effectively.

The service worked with other providers to deliver shared care and when patients moved between services.

Leaders demonstrated that they maintained oversight of workflow tasks to ensure timely responses.

The service showed a strong commitment to safeguarding, taking prompt action to protect individuals from abuse and neglect through effective collaboration with partners. Monthly internal meetings were held to discuss safeguarding issues, and children who missed appointments were actively monitored. Both clinical and non-clinical staff understood how to report concerns appropriately. Safeguarding concerns were consistently shared in a timely and appropriate manner, and patient records confirmed that vulnerable individuals were flagged for staff attention. Staff were well-trained in safeguarding procedures, and policies were clearly understood and effectively implemented.

Staff worked with individuals to help them understand and manage risks. They delivered care that was safe, supportive, and tailored to meet people’s needs. Patients received advice about risks related to their condition and were given guidance on what to do if their condition worsened and when to seek help.

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.

The service had a comprehensive suite of policies and procedures tailored to the specific needs of the practice which addressed various risks, including amongst others: fire, flooding, loss of computer or telephone systems, and staff shortages.

During our on-site assessment of both the main site and the smaller branch surgery, we observed that the premises were clean, well- maintained, and conducive to safe care. The service had effective systems in place to monitor and comply with mandatory risk assessments, including fire safety and legionella testing, helping to ensure the safety of both patients and staff. Records confirmed that medical and other electrical equipment was regularly maintained, calibrated, and tested.

A business continuity plan was in place and subject to regular review to ensure preparedness for potential disruptions. We saw evidence that the plan had been recently activated and also saw that the procedure had then been reviewed for learning opportunities.

The practice ensured that there were sufficient qualified and experienced staff who received effective support and supervision. Staff worked well together to deliver safe care that met people’s individual needs, and the team had reported feeling supported by the leadership team.

Staff were equipped with the necessary knowledge and skills to deliver safe, effective, and person-centred care, and the provider-maintained oversight to ensure training remained up to date and relevant.

Staff recruitment practices were effective and followed the recommended guidance.

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

Medicines were managed safely and in line with legislation and evidence-based guidance. 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. Patient feedback included individual examples of discussions with a GP to ensure understanding of proposed changes to prescribed medicines.

Staff received training in medicines management and reported feeling confident in handling the storage, administration, and documentation of medicines. They held the necessary authorisations to administer medicines, including Patient Group Directions and Patient Specific Directions. Medicines-related stationery was managed securely, and staff followed established protocols to ensure safe prescribing practices.

The provider had robust systems in place to manage safety alerts and medicine recalls. Staff took proactive steps to ensure prescribing was appropriate and aimed at optimising outcomes, including the responsible use of antibiotics. Prescribing data reviewed during the assessment supported this, showing that the provider issued fewer hypnotic and psychotropic medicines compared to local and national averages.

A programme of regular two-cycle clinical audits focused on prescribing practices, aiming to continuously improve care and treatment.

As part of the assessment, a series of clinical record searches was carried out by a CQC GP Specialist Advisor, with the provider’s consent. These searches aimed to assess whether the service was delivering care and treatment in line with current legislation, standards, and evidence-based guidance. We found that generally, medicines were prescribed safely, and medication reviews were up to date. We identified 3 people who required attention and during the assessment, all 3 patients were contacted.

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 in a safe, locked and away from patient access. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments.