Limestone 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 81 (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 strong proactive and positive culture of safety, based on openness and complete honesty. They actively listened to concerns about safety and thoroughly investigated and reported safety events. Lessons were always learnt to continually identify and embed good practice.

Robust systems were in place for reporting, investigating, and learning from incidents, near misses, and complaints. When things went wrong, patients received timely apologies and appropriate support. Learning was systematically embedded into practice, resulting in improvements to care. For example, following an incident where a patient referral remained unprocessed in the inbox of a staff member who had left, the practice undertook a full audit of staff inboxes and introduced enhanced monitoring processes to ensure continuity and oversight.

The practice maintained clear governance processes, including annual significant event audits and complaints reviews which included thematic analysis, reflective learning, and evidence of changes implemented in response to identified trends.

Leaders demonstrated a strong capability to interpret safety information to identify not only individual risks but also wider system issues. Learning was applied across key areas including clinical care, safeguarding, medicines optimisation, premises management, access, and business continuity. This was evidenced through actions such as a comprehensive cold chain risk assessment, relocation of vaccines to a Primary Care Network (PCN) supported refrigeration system, implementation of a power outage standard operating procedure, and appropriate escalation to NHS Property Services and the Integrated Care Board. These risks were subject to regular review and monitoring.

The practice undertook a population level naloxone risk assessment, demonstrating a shift from a reactive, emergency response model to a proactive, community-based approach to overdose prevention, with a clear focus on those at highest risk.

The practice identified a cohort of patients at increased risk due to opioid use and assessed both the location and timing of potential overdose events. This highlighted that many patients were most vulnerable in community or home settings, prompting the adoption of a targeted, community based risk mitigation strategy. In response, the practice reviewed its patient registers and implemented measures to ensure appropriate access to take home naloxone. As a result, it was able to demonstrate that 100% of identified high-risk patients had been offered and had access to take-home naloxone, supporting timely intervention and reducing the risk of fatal overdose.

Overall, the practice showed a well embedded and mature safety culture, characterised by strong governance, proactive risk management, and collaborative system working, resulting in sustained improvements to patient safety and quality of care.

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.

Effective systems were in place for processing information relating to new people including the summarising of new records. The service worked with other providers to deliver shared care and when patients moved between services.

Systems were in place to ensure that all patient information, including laboratory test results and referrals, was reviewed and actioned in a timely manner. Referrals to specialist and urgent services, including two-week wait (2WW) referrals, were managed through a clearly defined process. The provider confirmed that these processes were monitored to maintain patient safety. In addition, staff provided patients with appropriate safety netting advice regarding worsening or deteriorating symptoms.

The service demonstrated strong safeguarding leadership and an embedded culture of safety, working proactively with people and system partners to understand what being safe meant to them and how this could best be achieved. Safeguarding was clearly prioritised across the organisation, with a strong and visible focus on improving people’s lives while protecting their right to live safely and free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. Concerns were consistently identified early and shared promptly and appropriately.

Safeguarding governance arrangements were robust, and effective. Policies were in place and understood by staff, supported by policies such as Child Was Not Brought, chaperone and mental capacity policies.

There were clear clinical leadership and accountability for safeguarding. A GP Safeguarding Lead for adults and children was trained to level 4 and was supported by a deputy safeguarding lead, a Prevent lead and a dedicated safeguarding administrator. This leadership structure ensured consistent oversight, and coordination of safeguarding activity across the practice.

Staff safeguarding training was up to date, with all non‑clinical staff trained to level 2 and all clinical staff to level 3. Training was reinforced through regular discussion, reflection and learning, ensuring safeguarding knowledge was actively applied in practice.

The practice demonstrated consistent multi‑agency working, with safeguarding leads routinely engaging with health visitors, social care, and other partners. Active participation in multidisciplinary and case review meetings enabled early identification of clinical, social and psychological vulnerability and supported timely, coordinated intervention to reduce risk and improve outcomes.

Safeguarding systems were developed and proactive. The practice maintained comprehensive registers for vulnerable individuals and families, including children subject to child protection plans, children in need, people with substance misuse issues and other vulnerable groups. These systems enabled leaders to maintain oversight, anticipate risk and ensure people received the right support at the right time. For example, registers ensured that looked after children consistently received their annual health reviews.

The practice used thematic safeguarding reviews and annual audits to identify recurring risks and emerging trends. Where increasing complexity or escalation of safeguarding concerns was identified, learning was reviewed in depth and safeguarding arrangements were further strengthened.

Safeguarding documentation and coding were reviewed and strengthened to improve both visibility and consistency across clinical records. This included a detailed review of 103 historical domestic abuse codes, 67 adults on the adult safeguarding register, and 56 children on the child safeguarding register to ensure records were accurate, up to date, and aligned.

Following a baseline safeguarding review in 2025, which identified variation in the recording of safeguarding, the practice developed a bespoke safeguarding template within the electronic system. This was designed as an additional prompt to promote professional curiosity, enhance recording standards, and reinforce a “Think Family” approach, ensuring that risks to all family members were consistently considered.

As a result, safeguarding was effectively embedded into routine consultations, with system-based prompts supporting timely decision-making and action. Staff demonstrated strong vigilance and confidence in identifying and responding to potential risks. A sample audit carried out between January 2026, and February 2026 demonstrated clear documentation of professional judgement, with explicit recording of actions taken or escalation where required. Clear referral pathways with local authorities ensured that information sharing was appropriate and timely.

All staff with chaperone responsibilities had enhanced Disclosure and Barring Service (DBS) checks, and all staff were up to date with safeguarding, Mental Capacity Act and Deprivation of Liberty Safeguards training in line with policy. These arrangements further reinforced a culture where safety, dignity and protection were integral to everyday practice.

The service 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.

Staff demonstrated a good understanding of emergency protocols and were trained in basic life support. Reception staff were aware of the actions to take if they encountered a deteriorating or acutely unwell patient and had been given guidance on recognising such presentations.

Patients were advised about risks related to their condition and the actions to take if their symptoms deteriorated. Staff were aware of the location of emergency medicines and equipment, which was appropriately maintained. The practice also held registers to support patients who were vulnerable or who had mobility or communication needs.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The premises were managed by NHS Property Services and shared by several healthcare providers. Health and safety and fire risk assessments were completed by the provider and staff received training in relevant health and safety topics, including fire safety, infection control, basic life support, and resuscitation.Policies and procedures were in place to support the effective management of health and safety. Fire safety policies were accessible, and staff were aware of how to locate these. Systems were in place to carry out regular checks of fire alarms, fire extinguishers, and evacuation procedures. Clear signage throughout the building provided guidance for staff and patients in the event of an emergency evacuation.

The practice operated from the ground floor and recognised that issues within shared premises could affect access, staff safety, infection prevention, vaccine cold chain resilience, and continuity of care. Leaders used established escalation routes to mitigate these risks. For example, following recurring power instability, the practice undertook a cold chain risk assessment, transferred vaccines to a Primary Care Network (PCN) protected fridge, implemented a power outage standard operating procedure, and escalated concerns to NHS Property Services and the Integrated Care Board (ICB) whilst longer term solutions were developed.

The practice maintained a business continuity plan that provided structured guidance in the event of significant service disruptions, including IT system failures.

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.

There were a range of clinical and non-clinical roles within the practice. We found training was up to date, learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence with supervision and oversight.

Staff were supported to deliver safe care through training, clear processes, and accessible leadership. Learning from incidents was used to drive targeted improvement. For example, following a prescribing incident, focused training was delivered to relevant staff, including new team members, alongside strengthened safety checks and clear escalation pathways. We found that staff were encouraged to raise and escalate concerns where uncertainty existed, which supported a consistent approach to delivering safe care.

Staff received support and opportunities to develop. All new staff underwent an induction programme and were required to undertake mandatory training within an appropriate timescale. There were systems in place to ensure that staffing levels met the needs of the service. Staff told us they felt there were enough team members to meet the needs of the service, and that they worked effectively together.

The practice made sure that staff were suitable for employment. Policies for appraisals and safe recruitment practices including Disclosure and Barring (DBS) and registration checks were in place. We reviewed 4 personnel files and found appropriate checks such as previous employment record, immunisation status and proof of identity checks had been completed.

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 (IPC) lead, and all staff had completed training relevant to their roles. Staff were aware of the systems and processes required to ensure clinical specimens were handled safely.

The practice had IPC policies in place, which were accessible to staff. These included additional policies covering hand hygiene, spillages, sharps or contamination injuries, and the handling of clinical waste.

An infection control audit was completed in December 2025 to identify potential risks and ensure appropriate action was taken where required. At the time of the assessment, the practice had achieved 98% overall compliance, with actions taken to mitigate risks. Where IPC risks related to the wider NHS Property Services managed estate, leaders ensured these were appropriately identified, recorded, and escalated. For example, carpeted flooring in clinical rooms had been repeatedly identified through IPC reviews as a hygiene risk. This was raised at a multi-agency estates meeting involving NHS Property Services, the Integrated Care Board (ICB), and the Local Medical Committee (LMC), where actions were agreed to review replacement with clinical-grade flooring.

Overall we found the practice used audit findings to identify risks and escalate these through system partners, and maintain oversight of unresolved environmental safety issues, demonstrating a proactive and systematic approach to infection prevention and control.

The service 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 was supported by clinical pharmacists from the local Primary Care Network (PCN) to monitor people and the prescribing of medicines. As part of our assessment, we carried out remote searches of clinical records to check how the practice monitored patients’ health in relation to the use of high-risk medicines.

Clinical searches identified 19 patients prescribed methotrexate, an immunosuppressant medicine, within the previous 6 months. We reviewed 5 patients and found that appropriate monitoring was in place in line with guidance.

We identified 609 patients prescribed angiotensin‑converting enzyme (ACE) inhibitors, commonly used to treat high blood pressure and heart failure. A review of 5 clinical records showed that all patients had been appropriately recalled for monitoring.

We found 5 patients prescribed aldosterone antagonist medicines, used to treat conditions such as heart failure, high blood pressure and fluid retention, who had not yet received a recent urea and electrolytes (UE) blood test to monitor kidney function and electrolyte balance. Of these, 1 patient was under the care of secondary services, and the remaining 4 had been appropriately recalled for monitoring.

The provider had systems in place to identify people with previously undiagnosed conditions. Clinical searches identified 6 patients who may have had a missed diagnosis of diabetes. A review of these records showed appropriate follow‑up action had been taken.

Our remote clinical searches identified 720 patients who had received a medication review within the previous 3 months. We reviewed a random sample of 5 records and found whilst medication reviews had been completed, staff did not always apply the correct clinical coding. Prescribing data showed that the practice performed in line with national averages for pregabalin and gabapentin, psychotropic medicines and hypnotics.

The provider was able to demonstrate they had processes in place in relation to safety alerts issued by the Medicines and Healthcare products Regulatory Agency (MHRA).

Emergency medicines, vaccines and medical equipment had clear monitoring processes in place. There were appropriate arrangements in place for the management of vaccines and for maintaining the cold chain. We saw fridge temperatures were routinely monitored and vaccines reviewed at random were in date and stored appropriately. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments.

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 and felt confident managing the storage, administration and recording of medicines. Staff managed prescription stationery appropriately and securely. Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics.