Eden 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. Managers encouraged staff to raise concerns when things went wrong. The clinical 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. They made sure there was continuity of care, including when people moved between different services. 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 patients 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 people who may be at risk and acted on concerns working in partnership with other organisations.

Systems and processes were in place to identify and raise awareness of groups of people who were potentially at risk. Safeguarding concerns were discussed at the monthly clinical meetings in addition to the bi-monthly children’s safeguarding meetings, and 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.

Systems were in place to check emergency equipment and medicines, although not always effective. We found one item was unavailable due to being used and not replaced, and this had not been identified during the routine checks. This was rectified during our visit. Portal suction was not available and a risk assessment had not been completed to identify and mitigate any risk. The provider told us they would review the situation and purchase suction equipment if agreed as required.

Staff could recognise a deteriorating patient and knew of action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated. The provider shared a positive example of staff action in response to a medical emergency in the service which supported the patients.

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.

A fire risk assessment had been completed, and staff completed online fire training and attended regular fire drills. A legionella risk assessment was in place and any required action as outlined in the action plans had been completed. Regular testing of water temperatures took place. Electrical and medical equipment had been tested and calibrated as required. There was a business continuity plan in place which was monitored and reviewed.

The electrical installation report completed in July 2025 indicated the condition was unsatisfactory. The provider told us the outstanding actions had been scheduled through third party contractors to be completed as a matter of urgency in the coming weeks. Cords to blinds were not secured to the wall in all areas, in line with a central alerting system (CAS) alert.

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 told us they recognised the recent increase in clinical staff (GPs and nursing team) had the potential to increase the workload for administrative staff and the current staffing levels were being kept under review.

There were 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. Staff were positive about the support, training and development they received.

The lead prescribing nurse was supported by the GPs as required during clinics and all discussions recorded. However, a formal process to review consultations was not in place. The provider had plans to introduce a formal process for review and feedback on the quality of consultations for the nursing team.

Safe recruitment practices were followed.

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 designated infection, prevention and control lead and all staff had had relevant training. Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks.

There were carpets in 3 of the clinical rooms and in the waiting rooms and corridors. The provider told us these carpets were deep cleaned every 6 months as identified on the cleaning schedules. However, the provider could not clearly demonstrate when the deep cleaning had taken place. We observed clinical waste awaiting collection was stored in an unlocked room.

Staff vaccination was maintained in line with current UK Health and Security Agency (UKHSA) guidance if relevant to their role.

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. Staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely. People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms. Medicine reviews were appropriate and well-structured. Processes were in place to provide assurance on the quality and safety of non-medical prescribing.

Our clinical searches identified people prescribed a disease-modifying antirheumatic medicine were well managed, and instructions on the prescription 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. 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. We saw the provider had already identified this area of risk and had been actively working to review this group of patients since April 2025.

Prescription stationery was stored securely. We looked at the system in place to record the receipt and use of prescription stationary. We found that all of the boxes in the cupboard were on the log, 2 boxes were open and both were half empty. The practice was unable to demonstrate whether prescription stationary had been used or was missing. The system in place for tracking prescription stationery was not effective. Staff logged the prescriptions put into a printer and all prescriptions were removed each night and stored in a locked cupboard. However, staff did not record what was removed from the printers at the end of the day, which meant the prescriptions left in the printer did not tally with the log.

Staff regularly checked the stock levels and expiry dates for all medicines and vaccines. Most of the recommended emergency medicines were available within the practice. Medical gases, such as oxygen, were stored securely.