Tower House 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 has changed to Requires Improvement.

The service was in breach of legal regulation in relation to safe care and treatment.

This service scored 59 (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. Lessons were learnt to continually identify and embed good service. The service investigated significant events, and these were observed to have been completed in a detailed process. Learning from significant events and complaints resulted in changes which improved care for others, for example, when people presented to the service with certain symptoms they were directed to the correct pathway for tests. However, learning from incidents and near misses not meeting the significant event threshold was not logged to enable a full culture of learning from trends. Staff felt there was an open culture, and safety was a top priority, however staff shared a strong desire for improved communication. 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. The service understood Duty of Candour and had responded to people where appropriate.

The service did not always work effectively with people or healthcare partners to establish and maintain safe systems of care. Our remote clinical searches identified concerns with how the service managed people’s blood test results. At the time of our review, there were 311 pathology results awaiting processing. The provider informed us these would be reviewed immediately. The searches also identified a number of clinical documents awaiting processing which required prompt action.

When we visited the service on 4 September 2025, a review had been completed and the number of outstanding results had reduced to 45, with the oldest result dated 3 September 2025. During our onsite visit, the service provided evidence of an action plan they had implemented to address the backlog of clinical documents, and this work remained ongoing.

There were systems in place for processing information for new people joining the service, and a dedicated member of staff was responsible for managing this. There was an effective system in place for tracking and managing outstanding summaries and the data is accessible as required however the quantity of outstanding summarisation records could not be recalled verbally during the inspection

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. Lessons were learnt to continually identify and embed good practice. The service maintained a list of vulnerable people and acted on concerns working in partnership with other organisations for example safeguarding meetings were held monthly to review the register. During the inspection, we checked a sample of Do Not attempt Cardiopulmonary Resuscitation (DNACPR) records for people. The service was able to provide evidence of an effective system to ensure DNACPR records remained up to date and relevant. The provider made sure children had been appropriately followed up with when they failed to attend appointments with primary or secondary care services. Safeguarding policies were in place however staff training records showed not all staff were appropriately up to date with their training in relation to safeguarding. The service had new staff undertaking training which would account for some of the shortfall.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs which was safe, supportive and enabled people to do the things which mattered to them. Staff had an emergency system should there be a need for support in an emergency, for example, clinic rooms and reception staff had access to a panic button. Emergency equipment was accessible for all staff at every floor and there were visible posters signposting people where the emergency equipment was. Emergency medicines and equipment was audited and checked.

The service did not always identify or manage potential risks within the care environment. Systems to ensure equipment, facilities and technology supported the delivery of safe care were not always effective.

Fire evacuation drills were not completed in line with the service’s fire safety policy. The policy required evacuation drills to be carried out every three months; however, these had not happened or were not being recorded. The issue had been raised as an outstanding action in the service’s previous three consecutive health and safety audits. The last documented fire drill had taken place in November 2024. The service completed a fire drill the day after our onsite visit and provided evidence of this. Fire wardens were in place on each floor, and both ground and first floor areas had suitable access and exit routes for people.

Health and Safety Law posters were displayed and contained the correct information. Contracts were in place to ensure premises maintenance; however, cleaning schedules completed by the external cleaning company were not available for review at the time of the inspection. Despite this issue, the service was observed to be clean and tidy, and all handwash dispensers were full and there were appropriate hand hygiene arrangements in place.

A business continuity plan was in place and was regularly reviewed. CCTV surveillance operated throughout the premises, with clear signage informing people of its use. Vaccine fridges were well managed and used solely for the storage of vaccines and medicines. Fridges were securely located in locked areas with access controls in place. Temperature monitoring was undertaken daily, and clear procedures were followed in the event of a temperature breach. Staff were able to describe the correct process for receiving vaccines into the service, including notifying the nurse immediately and ensuring vaccines were stored in line with the cold chain protocol.

The service did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work well together to provide safe care and met people’s individual needs.

We reviewed 4 staff recruitment records and found all lacked proof of photographic identity. One member of staff was missing a second reference, and there were no completed application forms or recruitment history available to confirm a full employment history had been obtained. Records of staff immunisations were also not available, and there was no evidence of appraisals or supervision taking place.

The service employed a range of clinical and non-clinical staff; however, there were no records of clinical supervision within personnel files. The service’s clinical supervision policy stated staff should receive formal supervision sessions every six weeks, but there was no evidence this was occurring.

Mandatory training compliance was not consistently up to date. For example, 14 staff had not completed required moving and handling training;7 staff had not completed Data protection training; 8 staff had not completed Learning Disability and Autism 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 service had a designated infection, prevention and control (IPC) lead and most staff had relevant training. Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks. The service had clinical waste bins externally and these were held securely. The service had a recent IPC audit completed by the local integrated care board in August 2025. The service had received an action plan and were in the process of completing this.

The service did not always make sure medicines and treatments were safe and met people’s needs, capacities and preferences. From our remote clinical searches, the service did not have effective systems in place to respond to safety alerts. For example, people’s medicine changes had not been checked in line with safety alerts; as out of 20 people prescribed escitalopram, 5 people required changes in medicines.

Staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely, however our remote clinical searches highlighted 3 of the 5 patients sampled on asthmatic inhalers required further review.

However, people knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms. Staff received regular training, were competency assessed on medicines optimisation, and felt confident managing the storage, administration and recording of medicines. Staff managed prescription stationery appropriately and securely. Medicines including controlled drugs were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines. Waste medicines were recorded and disposed of appropriately including medicines returned by people. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments.