Lawrence Hill Health Centre

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 requires improvement. At this assessment, the rating has changed to good.

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 did not always have a proactive and positive culture of safety based on openness and honesty. They did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Staff and leaders told us they were a learning organisation based on openness and honesty. However, learning from some incidents and complaints was not alwaysidentified for investigation.

The service had made improvements in the systems and processes regarding learning events since the last inspection. Now, learning events were recorded and investigated more consistently. However, during the onsite visit, we viewed examples of learning events and found although improvements had been made, not all areas of concern were identified to continually learn, take action and embed good practice. For example, we viewed an incident where a medical procedure was carried out twice on someone instead of only once. We reviewed the learning event analysis for this incident and areas for learning were not identified for investigation. The clinician that carried out the 2nd procedure stated they did not see the 1st clinician’s notes, but this did not appear to be explored as an area to investigate further and learn from.

The service had made improvements in their complaints processes since the last inspection. Now, complaints were more consistently recorded and investigated. We saw examples of learning being identified, which had led to an improvement project to review all pop-up messages on the electronic records system. However, we also reviewed examples of complaints which did not always follow the service’s own complaints process and therefore, areas for learning were not always identified and actioned. For example, we saw a complaint had come into the service, but it was not logged as a complaint and therefore not acknowledged, not thoroughly investigated and no learning identified. There were also actions noted regarding this complaint, but it was not recorded if these actions had taken place. Following the onsite visit, the service took action to review the effectiveness of the documents used during these processes and implemented a new regular governance meeting to ensure learning and actions are reviewed.

Staff were able to share examples of action taken following learning events and learning was a long-standing item on the weekly staff email newsletter.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

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 service had made improvements in their systems and processes regarding health and safety since the last inspection. Now, health and safety risk assessments and audits had been undertaken and risks they identified had been addressed.

The service did not always follow required recruitment procedures or ensure staff were suitably trained.

During the onsite visit, we reviewed 3 staff files for people recruited since the last inspection. We found gaps in the expected evidence set out in national legislation. For example, all 3 staff files were missing a pre-employment health check. One staff file was also missing evidence, such as, a DBS check, proof of identify and employment history.

We were shown a newly implemented recruitment policy and checklist that contained all the necessary pre-employment checks in line with national legislation. Following the site visit, the service undertook an additional review of this policy to ensure robust measures were in place to confirm that staff employed at the service, regardless of their employment status, were safe and suitable to work there. This new process needed time to be embedded into the service when recruiting staff in the future. The service also took action to seek assurances for the 1 member of staff missing a DBS check, proof of identity and employment history.

There was a process to oversee training, but this was not always effective. During the onsite visit we reviewed training records for 3 members of staff and found all were missing training the service deemed as mandatory. For example, 1 member of staff had not completed in-person training to support people with a learning disability, or autistic people and their safeguarding children training expired in October 2025. Another staff file did not contain any information on training they had been assigned or completed. Following the site visit, the service took action to address our concerns by creating a training action plan to ensure compliance with mandatory training within 4 weeks.

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 onsite visit, we reviewed training records for 3 members of staff and found 1 had not completed training in infection prevention and control (IPC). We also identified 25 staff members were allocated sepsis training but 5 had not completed it. Following the site visit, the service provided evidence this training had been completed by all staff it was allocated to.

Cleaning schedules were in place. However, they were not always signed off appropriately and there was no process to ensure they were being followed and signed off. For example, we saw examples where these had not been signed since 25 June 2026 and another example of a schedule being signed off the day after the inspection. The service was aware of issues with the external cleaning company and were taking steps to address concerns.

There was a process to obtain evidence of routine vaccinations for staff in line with guidance. However, we reviewed records for 3 members of staff and found 1 did not contain any evidence of routine vaccinations. Following the site visit, the service took action to request this evidence.

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.

Prescription stationery was now managed appropriately and securely.

The service had risk assessed and stocked appropriate emergency medicines which were regularly checked.

During the onsite visit, vaccines were viewed to be stored on the bottom shelf of a fridge which could lead to poor air flow and potential freezing of stock. Following the onsite visit, the service took action to address this by relocating the vaccines to a different shelf in the fridge and reminding staff of the cold chain policy.