King Edward Road 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. The practice had established systems to assess, monitor and improve the quality and safety of services. There was strong evidence of a positive learning culture where staff felt able to raise concerns and share learning. Managers investigated incidents thoroughly and used learning to support service improvement. People were protected from avoidable harm and risks to their safety were appropriately managed. Premises and equipment met people's needs and were clean and well maintained. There were sufficient clinical staff with the skills, qualifications and experience required to provide safe care and treatment. Managers ensured staff received regular appraisals and a system was in place to monitor mandatory training and support compliance. There were effective processes for monitoring patients prescribed medicines, including those requiring regular review. This key question has been rated as good.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice listened to concerns about safety and investigated and reported safety events. The practice had processes for staff to report incidents. Reporting forms were used and there was evidence incidents were investigated thoroughly. Themes were identified and lessons were learnt to continually identify and embed good practice. Staff described a no blame culture and said they were encouraged to report incidents. They were able to recall events and improvements made as a result to reduce future risks.

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 practice 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, including provision for shared care where necessary. There were effective systems in place for processing information relating to new patients. Leaders advised there were dedicated staff to support timely registrations and review of new patient records to ensure clinical staff had up to date knowledge when reviewing patients. In addition, the provider had invested in a digital service to support with new registrations to ensure prompt access to priority information, such as safeguarding. There were systems in place for managing incoming correspondence for patients’ medical records. Referrals and test results were managed in a timely way.

The practice worked effectively with people and partner organisations to understand what safe care meant to them and how best to achieve it. There was a clear focus on improving outcomes while protecting people from bullying, harassment, abuse, discrimination, avoidable harm and neglect. Concerns were shared appropriately and without delay.

There was a safeguarding team, comprising a clinical and non-clinical lead. Staff were aware of who the safeguarding leads were. The safeguarding team maintained oversight of lists of vulnerable people which were reviewed regularly. In addition, the clinical lead had developed highly effective practice specific digital systems that instantaneously alerted staff when vulnerable patient records were accessed. This system made critical information readily available to ensure appropriate support was offered. Leaders told us their safeguarding systems were highly commended within the locality.

Staff understood how to identify, report and respond to safeguarding concerns. They worked effectively with other agencies and healthcare professionals to ensure concerns were managed appropriately. There were effective systems for the identification, oversight and review of safeguarding issues. Safeguarding policies were available to staff, who had received appropriate safeguarding training. Regular safeguarding meetings were held, supported by ongoing communication between meetings.

The practice acted promptly on safeguarding concerns and worked in partnership with other organisations to protect people. For example, they monitored and followed up children who attended accident and emergency departments or did not attend scheduled appointments. We saw safeguarding information and sources of support displayed throughout the practice for both staff and patients.

Staff worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs which was safe, supportive, and enabled people to do the things which mattered to them. Emergency equipment was available and maintained. The service managed significant events effectively. 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 practice was fully aware of all potential risks in the care environment and controlled them well. They made sure equipment, facilities and technology supported the delivery of safe care. Portable appliance testing and calibrations were completed. There was a business continuity plan in place which was monitored and reviewed. 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 or were planned to be addressed. Systems were in place to check safety equipment including fire alarms and emergency lighting. Fire evacuation drills had been completed. We observed fire exits were clear and fire safety equipment was easily available and regularly checked. Staff were aware of what to do in an emergency and where emergency medicines and equipment were stored. Allocated staff also knew how to safely manage spillages of bodily fluids.

Leaders made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked collaboratively to provide safe care that met people’s individual needs. The practice employed non-medical prescribers and had established formal processes in place to monitor and audit their clinical practice. This formal process included audits of their prescribing practice, regular appraisals, feedback and support. A sample of staff files we reviewed showed staff were suitably qualified, maintained their professional registrations and their continuing professional development (CPD) and had up-to-date specialist training appropriate to their role. All staff had appraisals, access to regular clinical supervision and protected time to complete their mandatory training. Leaders maintained effective oversight of professional staff registrations and staff completion of training. During our assessment, we found all staff were up to date with their training. We reviewed evidence that demonstrated safe recruitment practices were followed.

The practice had systems to assess and manage the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. Leaders ensured that facilities and equipment were safe, and that equipment was maintained according to manufacturers’ instructions. The practice had a designated infection, prevention and control (IPC) lead and all staff had had relevant training. We noted the lead had not undertaken any additional training to support their role. We discussed this with the leadership team who later confirmed they had arranged for the lead to undertake further training in January 2027. Cleaning schedules were in place and followed. There was a policy for IPC available to all staff. Risk assessments and audits were completed, and actions taken to mitigate risks.

As part of our assessment, a GP specialist advisor undertook a series of patient clinical record searches, to assess whether clinicians were prescribing a range of medicines safely and whether patients were being reviewed in line with national guidelines. The results of our searches were positive.

We reviewed patients prescribed a disease-modifying antirheumatic drug (DMARD) used to treat active rheumatoid arthritis and psoriatic arthritis by suppressing the immune system to reduce joint inflammation, pain, and stiffness. It is often prescribed to slow disease progression and prevent structural joint damage. The search identified 40 patients prescribed this medicine and we reviewed records for 5 patients. We found all patients reviewed were receiving appropriate monitoring.

There was a process in place for recording and sharing Medicines and Healthcare Products Regulatory Agency (MHRA) safety alerts. Safety alerts were discussed in clinical meetings. Our clinical records review highlighted that safety alerts were not always actioned in line with guidance. Specifically, we reviewed patients prescribed teratogenic medicines to check they had received appropriate monitoring as required. (Teratogenic medicines are known to increase the risk of congenital malformations or developmental disorders when taken during pregnancy, especially in the first trimester). Our search identified 15 patients prescribed these medicines and we reviewed records for 5 patients. We found some gaps in record keeping, particularly documentation for discussions relating to the provision of pregnancy prevention plans (PPPs) and completion of annual risk assessment forms (ARAFs). We discussed our findings with clinical leads and further investigation highlighted that for some of these patients their care needs were complex and some were being managed by specialists in secondary care. Clinical leads were already aware of the need for further improvement in this area and discussed their plans with us. During the course of our assessment, the provider submitted an action plan detailing how they would reduce identified potential risks through targeted recall and review of patients. Standard operating procedures had been developed for ensuring appropriate documentation was completed and readily available. This evidence was reviewed by our GP specialist advisor who agreed the risks had been sufficiently minimised.

We reviewed patients potentially at risk of having a missed diagnosis of diabetes. Our search identified 33 potential patients, and we reviewed records for 5 of these patients and found none of them had diabetes.

Our searches identified a total of 850 medication reviews that had been completed for patients in last 3 months. We reviewed a random sample of 5 of these medication reviews and found that all reviews had been completed appropriately.

We reviewed the prescribing of medicines used to treat pain to ensure appropriate monitoring systems were in place. Our search identified 67 patients, and we reviewed records for 5 of these. We found that all 5 patients had been managed appropriately.

The practice adhered to an antibiotic stewardship policy that measured the appropriate use of antibiotics and optimised the use of antibiotics to improve patient outcomes. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.

Staff regularly checked medicine stock levels and expiry dates, including emergency medicines and vaccines. Medical gases such as oxygen were stored safely. Risk assessments had been undertaken for the location and storage of emergency medicines and equipment. Fridge temperatures were monitored daily, and staff knew what action to take if the temperature was out of range. Following discussions during our assessment, leaders advised they would purchase thermometers to enable monitoring of room temperatures where medicines were stored for safety. Confirmation these had been purchased was evidenced immediately following our assessment. Staff managed prescription stationery appropriately and securely.