Cumberland House

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 staff protected people from avoidable harm and made sure care was delivered from environments that were clean and well maintained. At our last assessment, we rated this key question as good. At this assessment, the rating remains the same.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

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

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 did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Staff and leaders did not complete health and safety risk assessments or undertook audits to ensure they had identified and addressed all risks. A risk register had been developed. Although the provider had completed an internal inspection of premise checklist, not all potential risks had been identified. For example, open fireplaces in consulting rooms, steps down to room 11, which was approached externally, and the use of fans within the building.

The provider had commissioned an external company to carry out a fire risk assessment in October 2023, with a review date of October 2024. The risk assessment identified a lack of emergency lighting in the building. The provider could not evidence that the risks identified had been mitigated as the action plan had not been completed or the assessment had been reviewed. The provider had completed a fire safety maintenance checklist in May 2026. However, this checklist did not identify the lack of emergency lighting or any action taken to mitigate the risk.

The most up to date legionella risk assessment completed by an external company seen during the visit was dated April 2019, with a review date of April 2021. Following the site visit the provider reviewed the risk assessment and forwarded an updated document detailing ongoing action taken to mitigate the risks. However, the provider told us an external company carried out monthly temperature checks and water sampling. The results of the most recent checks were not available at the time of the visit. The provider shared the checks following the site visit and these were found to be satisfactory.

The service had a business continuity plan which was regularly reviewed and outlined how the service should continue to operate in the event of a disruption. A system was in place for recording prescription stationery upon receipt at the practice, and only one printer was in use to reduce the circulation of prescriptions within the premises. However, there was no effective system for tracking prescription stationery throughout the practice. Access to the cupboard to where boxes were stored was not restricted during the day.

The service made sure there were enough qualified, skilled and experienced staff. However, they could not demonstrate that all staff received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The service employed a range of clinical and non-clinical roles, which included GPs, advanced nurse practitioners and practice nurses. In addition, the service utilised staff employed through their local Primary Care Network, providing a broader range of services to people. These included urgent care practitioners, community link advisor (social prescriber), mental health practitioners, first contact physiotherapist, clinical pharmacists, pharmacy technicians, GP assistant and care coordinator. They worked well together to provide safe care that met people’s individual needs.

Not all staff were up to date with training that the service had identified as mandatory. While the practice advised that processes were in place to remind staff to complete their required training, our findings indicated these processes required strengthening to ensure all staff remained compliant with mandatory training requirements. Staff told us they received support, supervision and learning and development opportunities. Non-medical prescribers and salaried GPs had daily support from the duty GP to discuss any issues or concerns, which was recorded, as well as attending clinical forums where they discussed cases with their peers and the partners. However, clinical supervision with oversight of consultations and prescribing was not formally documented. Staff, with the exception of salaried GPs, received an in-house annual appraisal.

The provider had not always followed safe recruitment procedures when employing staff, which were in line with national legislation. This included obtaining a recent photograph, evidence of up-to-date criminal records check prior to employment, exploration of gaps in employment or health declarations. Disclosure and Barring Service (DBS) checks were not obtained for non-clinical staff and a risk assessment was not place outlining the rationale and actions to mitigate any potential risks.
 

The service generally assessed and managed the risk of infection. They mostly detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service’s infection prevention and control (IPC) lead had completed additional training to support their role. They had completed an IPC risk assessment in June 2026, updated in July 2026 to ensure compliance and action taken where necessary to mitigate any identified risks. An action plan had been developed to capture areas that needed to be addressed. Regular handwashing audits had also been completed. However, not all staff had completed relevant training in infection prevention and control.

The service employed contract cleaners to clean the building. Cleaning schedules were completed on a daily basis and available for inspection.The service also had internal room cleaning schedules, which outlined how staff should clean the room they were working in and its equipment at the end of each clinic / working day. These were not always completed daily, and the service could not demonstrate how these were monitored for completion to maintain oversight of cleaning arrangements. The IPC lead told us they planned to introduce a new paper based system for monitoring and auditing the internal room cleaning schedules. During our onsite visit, the service's premises and a sample of equipment reviewed was noted to be visibly clean.

The provider had not completed a risk assessment for the Control of Substances Hazardous to Health (COSHH) and or obtained product data sheets for all products used within the service. We observed 2 COSHH products accessible in 2 consulting rooms. The provider removed these immediately once notified.

The provider could not demonstrate staff vaccinations were maintained in line with current UK Health and Security Agency (UKHSA) guidance relevant to their role. We looked at 4 staff records. Risk assessments had not been completed when vaccination records were incomplete, although the provider told us this was work in progress for non-clinical staff. The provider had not assured themselves the immunity had been achieved for those staff vaccinated against Hepatitis B.

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