Lockwood 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 69 (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 systems and processes in place to report, record and investigate incidents, significant events and near misses. Staff we spoke with understood how to report concerns and were able to provide examples of incidents they had raised. Staff told us managers encouraged them to raise concerns when things went wrong and supported an open culture of learning.

Incidents and learning events were discussed during clinical meetings and, where appropriate, shared with the wider practice team. Minutes of meetings were maintained and were available to staff on a shared computer drive. The practice also reviewed incidents for themes and trends to identify opportunities for improvement.

We reviewed a significant event involving an urgent referral that had been submitted for the wrong patient. The practice had investigated the incident, identified learning and implemented actions to reduce the risk of recurrence.

The practice had a system for managing complaints. Verbal complaints were generally resolved locally, while more complex or written complaints were managed by a centralised complaints team. We reviewed three complaints and found they had been acknowledged and investigated. However, final responses were not always sent within the timescales outlined in the practice policy. Following the assessment, the provider explained that holding letters had been issued for the complaints we reviewed, however these were not available on the day of the onsite assessment. The practice advised they had recently implemented a new complaints management system to strengthen oversight and monitoring of response times.

At the time of our assessment, there were no complaints being considered by the Parliamentary and Health Service Ombudsman.

The practice worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed and monitored. They made sure there was continuity of care, including when people moved between different services.

The practice had systems in place for processing information relating to new patients, although they had identified a backlog in the summarising of medical records. At the time of the assessment, 84% of records had been summarised. The practice had completed a risk assessment and had implemented mitigating controls to reduce risks to patients whilst the backlog was being addressed. This included reviewing GP to GP transferred records on receipt to ensure key clinical information had transferred correctly and comparing registration information with patient records to identify any missing information, including allergies, current medicines and long term conditions.

Staff described clear processes for managing referrals, including monitoring patients referred under the two-week wait pathway. Audits were undertaken to provide oversight of referral management.

There were effective systems for managing incoming correspondence, pathology results and medication changes. Results were allocated daily to available clinicians to reduce the risk of delays in results being reviewed and actioned. The practice also operated recall systems to monitor patients' ongoing healthcare needs and support timely access to reviews and follow up care.

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.

The provider had appointed safeguarding leads and deputies for both children and adults. Safeguarding policies and procedures were in place and included guidance on staff responsibilities and training requirements. All staff had completed safeguarding training appropriate to their roles.

Staff we spoke with understood their safeguarding responsibilities and were able to explain how they would identify and escalate concerns. Safeguarding was discussed during clinical meetings and protected learning time to support awareness and learning.

Vulnerable patients and families were highlighted on the practice computer system, helping staff to recognise and respond to safeguarding risks. Safeguarding concerns were shared appropriately within the practice and with partner agencies when required to support patient safety and wellbeing.

The practice offered a chaperone service. Staff undertaking chaperone duties had received appropriate training and chaperoning was recorded in patient records.

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.

National GP Patient Survey results showed that 84% (national average 91%)of patients felt involved as much as they wanted to be in decisions about their care and treatment. Staff told us they worked collaboratively with patients to support informed decision-making and help them understand and manage risks associated with their health and treatment.

The practice had systems, processes and equipment in place to respond to medical emergencies, including emergency medicines, oxygen and an automated external defibrillator (AED). Staff had completed training appropriate to their roles, including basic life support and sepsis awareness training, and were able to describe how they would recognise and respond to a deteriorating patient.

During our review of emergency equipment, we found one out of date paediatric mask and noted that weekly emergency equipment checks had not been completed for a two-week period during a staff absence. We raised this with leaders during the assessment, who were unable to provide any further information on the practice's procedure for these checks when the lead nurse was on leave. Following the assessment, the practice provided evidence that they had reviewed and strengthened their processes. Responsibilities for completing checks during periods of staff absence had been clearly assigned, monitoring arrangements had been enhanced and automated reminders had been introduced to support compliance. The practice also provided evidence of ongoing compliance with weekly checks.

The practice had systems in place to manage environmental risks and support the safe delivery of care. Premises maintenance schedules were in place, and risk assessments had been completed for fire safety, Control of Substances Hazardous to Health (COSHH) and health and safety. During the assessment, some surgery-specific risk assessments appeared to be out of date. Following the assessment, the practice provided evidence that these assessments had been reviewed and completed prior to our visit. A health and safety audit undertaken in March 2026 provided additional oversight of environmental risks.

The practice had arrangements in place to support fire safety. Fire alarm testing and fire evacuation drills were undertaken regularly, fire extinguishers had been maintained in line with requirements and trained fire marshals were in place. Health and safety information was available to staff, and an accident book was maintained. The practice also provided evidence of a legionella risk assessment completed in June 2026.

The environment supported the safety of patients, visitors and staff. Security lighting was installed in the car park and around the outside of the practice. During the assessment, we found the emergency pull cord in the accessible toilet did not extend to floor level, which meant it may not have been accessible to a person who had fallen.

The practice 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.

Leaders told us that staffing levels were monitored to ensure there was an appropriate mix of clinical and non-clinical staff available to meet patient need. The practice used a digital management system to monitor workload, capacity and service demand, enabling leaders to identify pressures and arrange additional support where required.

The practice had recruitment and onboarding processes in place. We reviewed four staff files and found Disclosure and Barring Service (DBS) checks had been completed where required and records relating to staff vaccination status were available. We found one file did not contain a signed contract and references were not always available. Following the assessment, the provider demonstrated a process for obtaining and monitoring references, including documenting decisions and risk assessments where staff commenced employment before references had been received.

Staff received role specific inductions, and an appraisal process was in place. Mandatory training records showed staff were up to date with training appropriate to their roles. Leaders had identified challenges in accessing the required Oliver McGowan Tier 2 training (learning disability autism training) and were working with local partners to source suitable training opportunities.

A clinical supervision policy was in place and staff told us they were able to access support when required. Although clinical supervision was not always formally recorded, staff described a supportive culture and opportunities for clinical discussion and learning.

The practice assessed and managed the risk of infection prevention and control (IPC). They detected and controlled the risk of infection spreading and took action to address identified concerns.

An IPC lead was in place, and formal training for the role had been scheduled. An IPC audit had been completed in May 2026, and monthly IPC audits were undertaken to monitor compliance. Actions identified through audits were discussed and plans put in place to support improvement. Staff completed IPC training appropriate to their roles.

The premises were mostly clean, tidy and free from clutter. Cleaning arrangements were managed by the practice, and cleaners used colour-coded equipment stored in designated areas. We found that some cleaning records had not been dated. The practice advised they were introducing a QR code monitoring system to strengthen oversight and provide assurance that cleaning tasks had been completed.

During the assessment, we identified that gloves used when handling clinical samples were being disposed of in general waste, leaders advised us that a clinical waste bin would be made available. We also found that one clinical room did not have access to hot running water, onsite there was no evidence or risk assessment for this. Following the assessment, the practice provided a risk assessment, evidence of mitigating actions and confirmation that remedial works had been scheduled.

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.

The practice had implemented systems and processes to support the safe prescribing, storage and monitoring of medicines. We saw evidence that staff actively involved people in reviews of their medicines and supported them to understand how to manage their medicines safely. Patients were provided with information about what to do and who to contact if their condition did not improve.

Medicines, including vaccines and emergency medicines, were stored securely and at appropriate temperatures. Staff routinely monitored stock levels and expiry dates, and arrangements were in place to respond to incidents affecting the safe storage of medicines. Prescription stationery was stored and managed securely. Medical gases, including oxygen, were stored safely and appropriate risk assessments had been completed.

The provider had effective processes for managing medicines safety alerts and recalls. Staff followed established procedures to ensure patients prescribed high risk medicines received appropriate monitoring and review.

As part of this assessment, a CQC GP Specialist Advisor completed remote clinical searches to review prescribing and medicines management processes. These showed that the practice had effective systems in place to monitor patients prescribed disease-modifying antirheumatic drugs (DMARDs) and other medicines requiring regular review. For example, 100% of patients prescribed DMARDs had received appropriate monitoring. Records demonstrated that relevant monitoring and medicines reviews were completed in line with practice protocols to support safe prescribing.