Brook Lane 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 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 75 (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 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 contracts to ensure the premise was maintained. Staff and leaders completed health and safety risk assessments and undertook audits to ensure they had identified and addressed all risks. The service had a business continuity plan (BCP) which was regularly reviewed and outlined how the service should continue to operate in the event of a disruption. For example, on the morning of our onsite visit, the access road to the service was blocked following a storm, and leaders were able to demonstrate how they had followed their BCP to safely ensure they could continue to operate. The incident was resolved prior to opening and did not impact the service. The service had an ongoing maintenance plan, overseen by leaders, with improvements they planned to make, for example, the replacement of fabric chairs with wipe clean versions.

Portable appliance testing (PAT) and equipment calibration had been completed and were routinely monitored. The service had a fire evacuation plan and policy, and fire alarm testing was undertaken weekly as per policy. Scheduled safety checks were conducted on the fire alarm system, emergency lighting and equipment.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together to provide safe care that met people’s individual needs.

The service employed a range of clinical and non-clinical roles, which included GPs, nurses, care co-ordinators and pharmacists. Leaders ensured staff were up to date with their training which the service had deemed mandatory and operated within their agreed areas of competence. The service followed safe recruitment procedures when employing staff, which were in line with national legislation. This included identity checks, review of qualifications, obtaining of professional references and 5 yearly criminal records checks which were in accordance with the service’s policy. Although health questionnaires were missing from staff records, the service promptly addressed this and confirmed immediate implementation after our onsite visit.

The service had a comprehensive induction programme for all new staff which supported their development and ensured they had enough guided learning and support to meet the competencies of their role.

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 completed relevant training.

Risk assessments and audits were completed and actions taken to mitigate risks, for example, legionella risk assessments and certificates were retained. Waste, sharps, and clinical specimens were managed in line with national guidance to keep people safe. Clinical rooms had adequate provision of personal protective equipment (PPE) and handwashing facilities. Hand hygiene audits were conducted.

The service had cleaning schedules available, which outlined how staff should clean the building and its equipment, including the schedule for carpets and fabric chairs. During our onsite visit, we noted the service to be clean and tidy with minimal clutter. However, there were no cleaning checklists completed by the external cleaning company and there were not sufficient colour-coded mops available for each designated area within the service to avoid cross contamination, in line with national guidance. Since our onsite visit, the service contacted the external cleaning company and have implemented cleaning checklists and all the required colour- coded mops in use.

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