Laurel Bank Surgery Also known as Malpas Surgery Laurel Bank Malpas

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 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 provider 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.

Staff felt able to raise concerns and understood how to report incidents and safety events. In April 2026, the practice took responsibility for 2 additional branch sites. Leaders described how the integration process identified areas requiring improvement, and staff were encouraged to raise concerns, share learning and contribute to the changes needed to strengthen systems and processes across the organisation. The provider demonstrated several examples where incidents, audits and reviews had led to changes in systems and processes. Leaders demonstrated insight into areas requiring improvement following the merger and showed a willingness to identify issues, implement changes and monitor progress.

Staff told us there was an open culture within the practice and they felt supported to raise concerns. Learning was discussed through governance meetings, protected learning time sessions and team discussions, helping to support continuous improvement across the organisation.

The provider 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 provider had clear arrangements in place to manage appointments, respond to urgent patient needs and coordinate care. They worked closely with community services, care homes and other healthcare providers, helping to ensure patients received joined-up care when moving between services. Referrals, letters from other services and test results were reviewed and acted on to support patients' ongoing care.

The provider took steps to identify and respond to safeguarding concerns and worked with partner agencies to help keep people safe. They worked with people and healthcare partners to identify risks and ensure care and treatment was delivered safely, and shared concerns quickly and appropriately.

Following the merger of the 2 branch sites, leaders identified that safeguarding arrangements and oversight were not consistent across all sites. In response, the provider carried out a comprehensive review of safeguarding systems and records. This included reviewing patient records, carrying out searches, working with social services and reviewing previous safeguarding concerns to make sure vulnerable patients were identified and received the support they needed. As a result, the provider established an active safeguarding register and strengthened safeguarding oversight through regular governance processes and safeguarding meetings. Staff had access to safeguarding policies, training and support, and safeguarding concerns were regularly discussed with partner agencies to help ensure patients received appropriate support and follow-up.

The provider worked with people to understand and manage risks, taking account of their individual needs and circumstances. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The provider had effective systems in place to identify and respond to risks to patient safety. Administrative staff were supported by clear guidance on recognising potentially serious conditions and knew when concerns should be escalated to a clinician. Patients identified as requiring urgent care were able to access same-day appointments where appropriate. Information received from hospitals, community services and other healthcare professionals helped staff identify changes in patients' needs and respond to emerging risks.

Emergency medicines and equipment were available and regularly checked. Staff had received training to support their safe use.

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

The provider had robust systems in place to manage health and safety risks. Risk assessments and COSHH assessments were available across all sites, reviewed regularly and accessible to staff through the provider's governance systems. There were processes in place to monitor the servicing, maintenance and safety checks of equipment and buildings.

Following the merger of the 2 branch sites, leaders identified that some environmental and safety arrangements at the branch sites were not consistent with those at the main site. In response, the provider carried out a comprehensive review of risks relating to buildings and facilities and developed an action plan to address identified gaps. This included electrical safety, fire safety, equipment testing and water safety arrangements. At the time of our assessment, most actions had been completed, with the remaining actions either booked, commissioned or awaiting the outcome of completed assessments and reports. Leaders maintained oversight of these actions through regular management and oversight processes and had arrangements in place for business continuity and emergency preparedness.

The provider 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.

The provider had effective systems in place to support workforce planning, recruitment, training and development. Staffing levels and skill mix were reviewed regularly to help ensure services could be delivered safely. Training, professional registration and appraisals were monitored through practice systems and staff were supported through supervision, competency assessments and ongoing development opportunities.

Following the merger of the 2 branch sites, leaders identified that recruitment records at branch sites were not always consistent with those at the main site. The provider recognised these issues and put an action plan in place to improve oversight and make processes consistent across all sites. At the time of our assessment, this work was ongoing. We also identified some gaps within a locum clinician's recruitment file, including missing evidence of right to work and professional registration checks. Leaders acknowledged these issues and had plans in place to strengthen assurance arrangements.

The provider had strong clinical supervision arrangements in place for pharmacists and advanced practitioners. Regular reviews, audit activity and clinical oversight helped ensure staff worked within their competencies and provided safe care.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The provider had clear infection prevention and control arrangements in place. An identified IPC lead oversaw infection prevention and control activity across the organisation. Policies, guidance and training were available to staff through established systems, and staff training was monitored regularly. Cleaning arrangements were in place and regularly reviewed to help maintain a safe environment for patients and staff.

The provider completed regular infection prevention and control audits and environmental checks to identify and manage risks. Leaders demonstrated good oversight of infection prevention and control arrangements across all sites and had identified opportunities for further improvement following the merger. Leaders also recognised that managing infection prevention and control across 3 sites had increased the responsibilities of the IPC lead and were reviewing the time allocated to the role to make sure effective oversight could continue.

The provider 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 provider had effective systems in place to manage medicines safely. A well-established clinical pharmacy team supported medicines reviews, long-term condition management and medicines safety. There were clear processes for managing repeat and higher-risk medicines to help ensure patients received appropriate monitoring and follow-up.

The provider had arrangements in place to manage medicines safety alerts and recalls, ensuring actions were reviewed and completed in a timely way. Medicines were stored securely and appropriate systems were in place to monitor stock levels, expiry dates and the management of controlled drugs. Staff carried out structured medication reviews to help ensure medicines remained safe and appropriate.

The provider also took a proactive approach to reviewing medicines and reducing unnecessary medicines use. For example, the provider demonstrated how patients had successfully reduced and then stopped opioid medicines following support and regular reviews, supporting safer prescribing and reducing the risk of harm.