The Paradise Road Practice

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 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 proactive and positive culture of safety, based on openness and honesty. All staff including non-clinical were made aware of all significant events. They had regular meetings to discuss them, and the agenda and minutes were circulated in case staff could not attend.

They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. Staff gave an example of a significant event which had occurred recently regarding a medicine error. The event was documented comprehensively and dealt with efficiently. Lessons learnt had led to improvements in the service. Other significant events had been recorded in the same comprehensive way.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. Representatives from the Patient Participation Group (PPG) told us that the provider took concerns seriously and proactively made improvements to the service. Managers encouraged staff to raise concerns when things went wrong. During staff meetings, the whole team discussed and learnt from clinical issues. Staff told us 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. We reviewed the complaints log, and it was managed in line with requirements. For example, complaints had been recorded consistently and in accordance with the provider’s policy. This included verbal complaints, which had been documented appropriately in the log. Each entry included the date received, a description of the issue, and the actions taken. We also saw that responses had been issued within the provider’s stated timescales, and outcomes had been clearly documented. 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.

There were systems in place for processing information relating to new patients, which were efficient and well‑integrated, supporting timely and accurate registration with appropriate safety checks. All newly registered patients were also offered a health check. 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. Two‑week‑wait and other urgent referrals were processed on the same day to meet clinical safety standards and ensure patients are seen promptly. Routine referrals were completed within one week, allowing sufficient time for administrative checks while maintaining timely access to specialist services.

Clinicians were aware of incoming referral requests and could action or approve them when required, ensuring clinical oversight was consistently maintained.

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 comprehensive and reviewed on a regular basis. There was a single policy that covered both children and adults. The policy outlined the different types of abuse. In addition to this there was extensive detail on signs and indicators for female genital mutilation and child criminal exploitation. All staff knew and understood the policies content.

The Lead GP was the designated safeguarding lead, and all staff we spoke with, and those who provided feedback, were aware of this. However, the training arrangements could have been improved, particularly to ensure all staff completed safeguarding training at the correct level. We raised this with the practice during the inspection, and they confirmed shortly afterwards that staff had now completed the appropriate level of training. To prevent recurrence, the practice has reviewed and strengthened its safeguarding training framework, including updating the Bluestream training matrix in line with current intercollegiate guidance. Additionally, the Safeguarding Lead was given responsibility for verifying updates through quarterly forums and going forward will undertake an annual safeguarding training audit.

The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations.

Information about how to escalate concerns to the local authority were available in the reception area, all consulting rooms, and the administration office. Staff described concerns they had dealt with, and this included examples of how they worked in partnership with other organisations. Safeguarding was also discussed internally, and we saw evidence of this in clinical governance meeting minutes.

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. Equipment and medicines were stored in a central place which was accessible to all staff. Staff we spoke with were aware of what to do in an emergency and demonstrated they knew how to use equipment. 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 ensured that all staff were confident and capable in responding to medical emergencies through structured training, equipment familiarisation and practical exercises. All staff had completed face‑to‑face medical emergencies training, and the practice also held internal drill exercises to reinforce these skills.

The service had robust systems in place to detect and control potential risks in the care environment. They maintained a safe, accessible, and inclusive environment by regularly reviewing the physical setting and ensuring it supported the diverse needs of the people who used the service. The practice manager had good oversight of the maintenance contracts in place. The practice used an external company to carry out their fire, legionella and general health and safety risk assessments. These were completed on an annual basis. There was a business continuity plan in place which was monitored and reviewed.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development.

Although the practice was small, there were a variety of clinical and non‑clinical roles. They worked together well to provide safe care that met people’s individual needs.

New clinicians received routine supervision and reviews, along with additional oversight at the start of their employment. The practice also had systems to ensure safe prescribing by the non‑medical prescriber pharmacist, including monthly audits.

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. 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 practice had a designated infection, prevention and control lead and all staff had had relevant training. Cleaning schedules were in place and followed.

For example, we had seen completed and signed cleaning records demonstrating that routine checks had been carried out. We had also seen an infection control audit, which showed the service had monitored compliance. In addition, we had spoken with the IPC lead, who told us they had conducted regular audits and maintained oversight to ensure standards were upheld.

There was a contract in place with an external contractor who carried out the cleaning. No concerns were observed during our on-site visit. Schedules were also in place for cleaning rooms and equipment. Every clinical room had an equipment cleaning schedule which were signed and dated by staff. There was a cupboard for all cleaning materials which was clean, tidy, and well organised. All rooms had sufficient supplies of liquid soap and paper hand towels.

Risk assessments and audits were completed, and actions taken to mitigate risks. We reviewed the last internal infection control and Health and Safety audits. No major actions were identified.

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. 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. Blank prescriptions were stored in a safe location and were locked away.

Staff followed protocols to ensure they prescribed all medicines safely, and ensured people received all recommended medicines reviews and monitoring. Medicines were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccine. We saw the records of the weekly and monthly checks completed by staff.

Waste medicines were recorded and disposed of appropriately. The provider had effective systems to manage and respond to safety alerts and medicine recalls. Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring.