Drs Sells and Dr Kyaw Also known as Lyngford Park 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 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 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.

Staff understood how to raise concerns and report incidents. Staff told us there was an open culture, and safety was a top priority. The service had processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints and incidents. When things went wrong, staff apologised and gave people support. The service held monthly meetings to discuss complaints and significant events. Learning was shared to improve people’s care. Meeting notes were shared with all staff, including those who could not attend. We saw evidence that the service managed complaints and incidents in line with their policies.

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.

There were systems for processing information relating to new patients. Staff had clear responsibilities and followed systems to ensure continuity of care between secondary and primary care. Test results, referrals and clinical correspondence were managed in a timely manner, with cover arrangements during staff absences. Designated administrative staff were responsible for managing and monitoring referrals to ensure people were referred to other services appropriately and were prioritised for urgent actions.

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.

The service had effective systems and processes to keep people safe and safeguarded from abuse.Alerts on clinical records flagged people with safeguarding concerns, including their household members.

The service had safeguarding policies for children and adults which were accessible to all staff. The policies contained detailed internal safeguarding processes, safeguarding training requirements and contact details of local safeguarding teams.

All staff had completed safeguarding adults and children training at the appropriate level to their roles. Staff knew who the safeguarding leads were. They could explain the safeguarding processes and felt confident in raising concerns. The service maintained lists of vulnerable children and adults which were regularly reviewed at multi-disciplinary team meetings with external partners such as health visitors and social workers.The safeguarding leads and administrators regularly attended safeguarding best practice meetings and forums organised by the local Integrated Care Board (ICB – an NHS organisation responsible for planning and funding of services for their local population) to keep up-to-date with safeguarding processes.

The service volunteered and participated in a pilot project from the local ICB on mandatory reporting of Female Genital Mutilation. The project was an initiative which promoted information sharing through a national electronic system and assisted with early intervention and safeguarding of young girls. Staff had received specific training as part of this project delivered by the local ICB.

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 could recognise a deteriorating patient and knew what actions to take. The service had a medical emergency policy which covered staff roles and responsibilities in the event if a patient’s condition worsened. The service held a medical emergency drill in October 2025 related to a cardiac arrest scenario to review how staff responded in an emergency. The service identified that while staff responded in a coordinated manner in line with the policy, there were areas for improvement. Follow-up actions from the drill were identified and completed, such as staff familiarising themselves with the location of medical equipment and medicines.

People were advised on risks related to their condition and actions to take if their condition deteriorated.

The service held appropriate emergency medicines and equipment.

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

Health and safety risk assessments and audits had been undertaken and risks identified had been addressed. This included fire safety and ensuring electrical equipment was safe to use and was calibrated, if needed, to ensure accurate measurements.

The service had a health and safety policy and a business continuity plan detailing what actions to take in the event of an incident which would affect the running of the service. There was a lone working policy to promote staff safety.

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 was a range of clinical and non-clinical roles in the service. Staff said there were enough staff to provide safe and high-quality care. The service carried out workforce planning activities to address areas where there were shortfalls in particular skills, such as additional nurses for conducting cervical smears and a healthcare assistant to provide wound care.

Safe recruitment practices were followed. We reviewed staff files which contained all relevant information as required in the regulations. The service conducted risk assessments to determine which vaccinations staff should receive depending on their roles.

Staff received an induction appropriate for their roles and staff were working in their agreed areas of competence. There were policies and processes for clinical supervision and staff had regular appraisals, which included conversations on professional development.

There was a process to monitor training compliance. Almost all staff were up-to-date with their training required by the service, apart from a few new starters. The service had plans for these members of staff to complete the training within 3 months of their start date.

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.

During the site visit, we saw the premises were visibly clean and tidy. The service had a designated infection prevention and control (IPC) lead, and all staff were aware of who this was. All staff had received relevant IPC training in line with their roles and responsibilities. The IPC policy was accessible to all staff. Staff knew how to manage clinical waste and specimens. Personal protective equipment (PPE) was available and there were hand-washing facilities in all clinical areas.Sharps waste bins used for disposing of used medical instruments such as needles or syringes were safely managed.

Staff from the external cleaning company followed cleaning schedules. The service regularly reviewed cleaning audits and discussed any issues with the cleaning company. The service completed a programme of IPC audits and risk assessments covering areas such as cleaning standards and disposal of clinical waste.

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 service had policies and procedures for the management of medicines. Non-medical prescribers (healthcare professionals who can prescribe medicines but are not GPs) received regular audits to ensure medicines prescribed were necessary, correctly prescribed and followed up when needed.

Vaccines were appropriately stored and monitored in line with national guidance to ensure they remained safe and effective.

The service had a process for authorising staff to administer medicines including Patient Group Directions (PGDs) or Patient Specific Directions (PSDs). (PGDs are a written instruction for the supply and/or administration of a named licensed medicine for a defined clinical condition. PSDs are a written instruction from a doctor or other independent prescriber for a medicine to be supplied or administered to a named patient.) Blank prescription stationery was securely stored and accessible only to authorised staff.

Emergency medicines and equipment held by the service were in line with guidance for GP practices; and were regularly checked to ensure there was sufficient stock and were safe to use. During the site visit, we observed the emergency trolley, which stored emergency medicines and equipment, was in a corridor leading to consulting rooms which promoted immediate access if necessary. However, the emergency medicines inside the trolley were not stored in a tamper-proof container to reduce the risk of unauthorised access. The service took immediate action to rectify this and implemented tamper-proof seals on the container of emergency medicines. However, this was not yet supported by formal governance processes to ensure oversight was embedded.

As part of our inspection, a number of set clinical record searches were undertaken remotely by a CQC GP specialist advisor. These searches were visible to the service. Our clinical searches showed people prescribed high-risk medicines received necessary monitoring to keep them safe. We sampled 5 clinical records to look at the quality of medicine reviews and found all of them were reviewed appropriately with good quality. We found people prescribed medicines to treat high blood pressure and people prescribed non-steroidal anti-inflammatory drugs who had not received monitoring, had been proactively identified by the service and contacted for a review.

Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. Prescribing data reviewed as part of our assessment confirmed this. For example, the number of antimicrobials issued by the provider was lower than national averages.