Marazion 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 in March 2015, we rated this key question as Good. At this assessment, the rating remains unchanged.

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 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.

During clinical meetings, the GPs, clinicians, and practice manager discussed and learnt from clinical issues. Minutes of these meetings were shared with all staff.

Staff felt there was an open culture, and that safety was a priority. The provider had processes for staff to report incidents, near misses and safety events.

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.

There were systems for processing information relating to new patients.

The service worked with other providers to deliver shared care and when patients moved between services.

Referrals were managed in a timely way. There was a system and process for monitoring and managing two-week wait referrals, (urgent requests for a hospital specialist to see a patient with symptoms thatmay indicate cancer, ensuring they are seen within 14 days); which all staff knew and followed. The clinical records systems had an in-built function which supported monitoring of 2 week wait referrals. This included enabling staff to check that the referral had been sent and cancer safety netting (advice given describing what someone should do if their condition got worse or they were not contacted by secondary care).

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.

Staff were aware of safeguarding policies and were appropriately trained in safeguarding procedures. Staff members were able to give examples of where they had spoken to the Safeguarding Lead when they had concerns about a person.

There were safeguarding registers held for both adults and children which were regularly reviewed at meetings with other relevant organisations. Updates were recorded in meeting minutes.

A review of safeguarding records showed that alerts were appropriately placed on patient records and their household family members.

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.

Emergency equipment was available and maintained. Staff could recognise a deteriorating patient and knew of action to take. We reviewed staff training records for sepsis awareness and evidenced all reception staff had received this training.

People were advised on risks related to their condition and actions to take if their condition deteriorated. GPs were available to support the receptionists with clinical advice where 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.

There were contracts to ensure the premises were maintained.

There was a business continuity plan, made up of several documents and policies, which was governed by the objectives of the service.

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 within the service. Safe recruitment practices were followed. We reviewed 4 recruitment files and evidenced that staff had appropriate recruitment checks, including references and a Disclosure and Barring Service (DBS) Checks. (Disclosure and Barring Service (DBS) is a check which enables employers to check the criminal records of current and potential employees to ascertain whether they are suitable to work).

We evidenced learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence.

There were processes were to ensure that staff were appropriately trained and had received an induction and ongoing training relevant for their role.

Staff said they were supported to progress in their career. The service implemented protected continuous professional development time for all staff, allowing them to complete their mandatory training and develop in areas that benefited people’s care. All staff were encouraged to attend courses and share new skills and knowledge with the wider staff team.

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 service had a newly designated infection prevention and control (IPC) lead and deputy. To ensure they were meeting the criteria for IPC, they had accessed support and guidance from IPC leads within the primary care network. Advanced IPC training for the lead and deputy, had been sourced and was scheduled for completion in January 2026. All staff received relevant training. There were cleaning schedules which were followed. Risk assessments and audits were completed. The overall IPC audit included multiple audits such as handwashing and hand hygiene audits, environmental cleanliness, and waste management. Monthly IPC checks were conducted to address any identified issues in a timely manner.

The service held records of staff immunisations. However, some records of GP partners were required and there was evidence of these being requested.

There were appropriate systems for waste and clinical specimen management.

The environment and equipment were visibly clean at the time of the site visit.

The service made sure that medicines and treatments were safe and met people’s needs, capacities, and preferences. They involved people in planning.

Staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely. This was accurately recorded in people’s consultation records. People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms.

There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.

Staff received regular training, were competency assessed on medicines optimisation, 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 those prescribed certain high-risk medicines were lower than average nationally. For example, people prescribed multiple psychotropics (medicines used to treat mental health conditions, affecting mood, perception, and behaviour).

The service had effective systems to manage and respond to safety alerts and medicine recalls.

The service stored medical gases, such as oxygen, safely and completed required safety risk assessments.

There were suitable processes for staff to follow when dispensing medicines Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics.

Staff followed protocols to ensure they prescribed all medicines safely, and ensured people received all recommended medicines reviews and monitoring.

As part of our assessment a number of set clinical record searches were undertaken by a CQC GP Specialist Advisor.

We evidenced during the clinical searches that there were effective reviews and monitoring of people with asthma and diabetes.

We reviewed the records of people requiring medicine reviews. We evidenced 3 out of 5 records reviewed had been coded as having this review on their records but did not have consultation records to support this.

Following our clinical searches, we obtained evidence at our site visit of the service which showed that these people’s clinical records had been reviewed. The provider had approached stakeholders to find out what to record when reviews related to medicines prescribed by secondary care services. All 3 records had been updated to reflect this, and a new system had been implemented to ensure records would now be completed in this manner.