Gladstone 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 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 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.

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. Managers encouraged staff to raise concerns when things went wrong. During clinical meetings, the whole team discussed and learnt from clinical issues. Staff felt there was an open culture, and that safety was a top priority. The provider had processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Learning from incidents and complaints resulted in changes that improved care for others.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. The practice held regular clinical meetings, and meetings with the wider multidisciplinary team, to discuss the care of people and ensure clear communication pathways between professionals such as the district nurses and health visitors. Local health care providers used the same electronic patient record system and could easily access information about people using the service.

There were systems in place for processing information relating to new patients. The service worked with other providers to deliver shared care and when people moved between services. Referrals and test results were managed in a timely way.

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.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations, for example health visitors, district nurses and the frailty team. Safeguarding concerns were discussed at the weekly clinical meetings and staff told us they were encouraged to raise any concerns they had with the safeguarding leads. The service worked closely with the local children’s safeguarding co-ordinator, who organised the bi-monthly children’s safeguarding meetings, and also attended the monthly community delivery multidisciplinary team meetings. There were systems in place to follow up people who failed to attend appointments in primary and secondary care or were frequent attenders to the emergency department.

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

The systems in place to check emergency equipment were not effective. We found the adult pulse oximeter was not working as the batteries were flat. The paediatric pulse oximeter was not located with the emergency equipment and staff were unable to locate it quickly. A risk assessment had been completed to identify and mitigate any risk associated with not having access to portable suction.

Following our assessment, the provider sent us their protocol for the use, tracking and return of paediatric pulse oximeters within the service. An additional pulse oximeter had been purchased, stored in the emergency bag and was to be used only in the event of an emergency. The main paediatric pulse oximeter was located at the front reception desk, and a tracking system introduced to record when clinicians removed and returned the equipment. This process ensured staff should always be able to locate the main paediatric pulse oximeter when required.

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

Contracts were in place to ensure the premises were maintained. Health and safety risk assessments and audits had been undertaken and risks identified had been addressed. For example, fire and legionella risk assessments. There was a business continuity plan in place which was monitored and reviewed.

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. Staff were positive about the support, training and development they received and there was protected time to complete mandatory training as identified by the service.

There was 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. There was a system of audit and clinical supervision to support non-medical prescribers. Safe recruitment practices were followed.

Leaders told us they recognised the practice population would benefit from an onsite phlebotomy service and were looking to recruit a phlebotomist in the near future.

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 had relevant training. Cleaning schedules were in place and staff signed daily to confirm they followed the schedule.

Risk assessments and audits were completed, and actions taken to mitigate risks. An IPC audit had been completed in September 2024 and an action plan put in place to address the risks identified.

Staff vaccination was maintained in line with current UK Health and Security Agency (UKHSA) guidance if relevant to their role. Where staff were unable to evidence immunisation status, risk assessments had been completed.

The service mostly 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.

Staff had the appropriate authorisations to administer medicines, although we noted some patient group directions had been signed by the authorising manager before the practitioners. There was an effective system for recording and acting on safety alerts such as Medicines and Healthcare products Regulatory Agency (MHRA) alerts. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments. There were systems in place to monitor the prescribing of non-medical prescribers.

Staff received regular training and followed protocols to ensure they prescribed all medicines safely. Although medicines were stored securely, the provider was not able to demonstrate all medicines were stored at appropriate temperatures, as room temperatures were not monitored. Staff regularly checked the stock levels and expiry dates of medicines and vaccines. Staff were aware of the actions to take in the event of a cold chain breach in the storage of vaccines.

The service did not stock 3 of the suggested emergency medicines. A risk assessment had been completed for 1 of these medicines. Following our assessment the provider sent us risk assessments for the remaining 2 medicines.

Prescription stationery was stored securely, however systems to log and track prescription stationery throughout the practice were not effective. The prescription boxes and prescription pads had not been logged on receipt. Records did not support effective systems for tracking prescription stationery. The number of the prescriptions which remained in printers did not tally with the records. Staff had not received training and did not follow national guidance when disposing of spoiled or unwanted prescriptions. They told us they had shredded a quantity of prescriptions on the day of our assessment, but they had not recorded the numbers of the shredded prescriptions. Following our assessment, the provider sent us an updated prescription policy, outlining the process for safe receipt, storage, destruction and tracking of prescription stationery throughout the practice. The provider also informed us they planned to use one designated printer in the future to reduce the movement of prescription stationary within the building.

Our clinical searches identified people prescribed a disease-modifying antirheumatic medicine were well managed, and instructions on the prescription generally included the day of the week for administration.

Systems were in place to manage and respond to safety alerts and medicine recalls. Our clinical searches identified that in the majority of cases appropriate action had been taken in response to safety alerts. However the service needed to assure themselves secondary care services had completed annual risk assessments forms, and pregnancy prevention plans had been discussed and documented for women of childbearing age prescribed a specific medicine.

Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring. However, our clinical searches identified the recommended monitoring was not always at the frequency required for frail people or those aged over 75 years prescribed medicine to prevent blood clots. The provider told us they had started to review this group of people to ensure those were required monitoring were included in the recall system and invited to attend for blood tests.

Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. However, prescribing data reviewed as part of our assessment indicated the number of broad-spectrum antibiotics issued by the provider was higher than the national average. In addition, the number of people prescribed multiple psychotropic medicine was significantly higher than the national average.