Cambrian 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 the same.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People felt supported 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 based on feedback.

Managers encouraged staff to raise concerns when things went wrong. Staff were aware of the significant event process and were able to share examples of events that had been discussed practice wide during recent meetings. Learning was discussed and disseminated and resulted in changes that improved patient care. A log was maintained of any significant events raised and staff described the practice’s culture as one of openness without blame.

We reviewed the complaints records and found there was an effective system to record and investigate complaints. Records showed that complaints were recorded and acknowledged in a timely manner and when things went wrong, staff apologised and gave people support. We noted that information within the patient complaint leaflet was inaccurate. The practice had since rectified this and sent us an updated copy.

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 and patients requiring care out of hours.

There were systems in place for processing information relating to new patients. The service worked with other providers to deliver shared care and when patients moved between services. Referrals and test results were managed in a timely way.

The service 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 service shared concerns quickly and appropriately.

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

Safeguarding meetings were held within the practice and all staff roles were represented at the meetings.

The service worked with people to understand and manage risks. However, effective systems were not always in place to ensure safe practices. Emergency equipment was available. The Emergency trollies were well laid out, it was easy to access items in an emergency situation, and information was readily accessible if required. The suggested medicines were held and clear reasoning given for each drug if a decision had been made not to stock the drug.

A random sample of emergency equipment (including medicines) was checked. We found several items out of date (some had expired in 2023 and 2024). These were removed and replaced when identified. One medicine was found out of date in one of the fridges. The practice told us that since the inspection, staff had reviewed the checking process to include supervision and spot checks, which included checking of expiry dates of emergency medicines. The checklist was also under review.

With the aid of a care navigation spreadsheet that had been created by the partners, 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.

The provider advised us they occupied 34% of the building with the remainder being occupied by community services. The provider detected and controlled potential risks in the care environment as much as they were able to. NHS Property Services were responsible for maintaining the premises and carrying out a range of health and safety checks. There had been some challenges with obtaining some health and safety records directly from the landlord to ensure the facilities supported the delivery of safe care, however, these were made available on the day of our site visit. Records sampled showed all of the required health and safety checks had been undertaken with the exception of 6 monthly fire evacuation drills. Records showed 2 fire evacuation drills took place in 2023 as a result of false alarms. No other fire evacuation drill had taken place, despite it being identified in the fire risk assessment dated 23/9/23. The practice told us they had raised this as a complaint directly with the landlord. The calibration of equipment and testing of portable appliances (PAT) were slightly overdue however, the provider was able to evidence the reason for this and provided us with a date they were scheduled to be completed. A portable heater was removed during our site visited as it had not been tested for safety since 2019.

A legionella risk assessment had been carried out for the premises in February 2025 and assessed as high risk. An action plan was in place; however, no completion dates were stated in this or the fire risk assessment.

There was a business continuity and recovery plan in place which had been reviewed and updated in April 2025, to reflect the location of a defibrillator on the ground floor.

The provider had carried out annual audits of accidents at work over the previous 3 years to identify any common trends and themes. We saw 12 accidents were recorded.

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. Staff reported they were provided with good training and development opportunities. Staff told us they would welcome additional staff to compliment the team including nursing and reception staff to meet patient demand for appointments.

There were a range of clinical and non-clinical roles within the practice. We found most training was up to date, learning needs and development of staff was managed appropriately and discussed as part of staff probation and appraisal. Staff were working within their agreed areas of competence. Where appropriate staff received clinical supervision. We sampled a range of supervision records and found staff generally received formal clinical supervision on a monthly basis. Records were detailed, signed and dated by both parties, and included learning points but were not linked to the patient consultation records reviewed for audit trail purposes. Following the site visit the provider actioned this and advised us they had since amended their clinical supervision form to include this information.

The practice had commissioned the services from a human resources (HR) consultancy firm to support them with their HR procedures. We sampled 3 staff records and found some omissions in safe recruitment practices, for example a lack of employment history for 1 staff member, no photo identification, satisfactory evidence of relevant qualification for 1 staff member or contract and immunisation status for a locum GP. Following our site visit most of the minor shortfalls were immediately actioned and confirmation sent to us, which included a revised staff recruitment policy and recruitment checklist and confirmation that a member of staff had returned from leave and was in the process of completing outstanding training.

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 temporary infection, prevention and control (IPC) lead and all staff had had relevant training. Staff had access to personal protective equipment (PPE) and arrangements were in place for the disposal of clinical waste. Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks. The areas we sampled during an environmental tour were visibly clean and hygienic. People we spoke with expressed no concerns relating to the cleanliness of the practice.

People were involved in the review of their medicines and staff helped them understand how to manage their medicines safely. They knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms. We noted that the medicine reviews were of a good standard and thorough.

Our remote clinical searches identified some shortfalls in relation to the effective and safe monitoring of people prescribed steroids for the exacerbation of asthma. We also noted that that not all patients on a drug to treat hypothyroidism had received the appropriate monitoring. During our site visit we received confirmation that all patients overdue monitoring had since been invited for blood monitoring of which 13 of the 69 affected patients had attended in the 3 days post our clinical search. The provider told us a new process was planned to be introduced to the clinical team around best practice guidance and expectations regarding reviewing patients prescribed steroids for exacerbation of their asthma.

Medicines were stored securely and at appropriate temperatures. Refrigerators used to store vaccines and medicines were monitored to ensure temperatures were maintained and products were appropriately stored within them. Staff regularly checked medicines held in the event of a medical emergency, however we found several items had expired. These were removed and replaced following our feedback. A risk assessment had been completed for the suggested medicines not held.

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.

Staff received training to support them in their role. The storage and security of blank prescription forms was adequate with access restricted to authorised individuals only. We reviewed all of the patient group directions (PGDs), (written instructions to help qualified health professionals supply and administer medicines to patients). We found only 1 PGD was valid. This was because they had been authorised prior to being signed by staff members responsible for administering the PGD. We also found lines were not crossed through on the PGD to avoid unauthorised entries. Following our site visit the provider told us they were reviewing their processes to achieve compliance with the safe management of PGDs.

Prescribing data reviewed as part of our assessment found practice performance was in line with national averages for Pregabalin and Gabapentin medicines (primarily anticonvulsant drugs, also prescribed for pain); psychotropic medicines (used to treat various mental health conditions); hypnotic drugs (used for the management of severe insomnia); and antibiotics.