Eldene Surgery Also known as Dr Philip Gnana Asirvatham Bauliah

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.

This is the first inspection for this service since its registration with CQC. This key question has been rated as Good.

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 strong proactive and positive culture of safety, based on openness and complete honesty. Leaders actively listened to concerns about safety and thoroughly investigated and reported safety events. Lessons were always learnt to continually identify and embed good practice.

Leaders encouraged staff to raise concerns when things went wrong. During staff meetings, the whole team discussed and learnt from clinical issues. The service anonymised these events and shared the learning within the local primary care network (PCN) meetings to improve patient safety wider and prevent similar events occurring in the future. Meeting minutes were made available to staff who were unable to attend these meetings. Staff told us there was an open culture, and safety was a top priority. The provider had processes for staff to report incidents, near misses and safety events, and staff provided examples of how incidents were investigated and resolved.

There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support in line with the duty of candour. Learning from incidents and complaints resulted in changes to improve care for others. For example, a new search function was developed within the service’s clinical system to identify any reports or letters without a linked referral, allowing for better monitoring of referrals. The service ran these searches daily to support timely referrals, ensuring people were directed to the appropriate specialists without delay, which improved overall care outcomes. Staff told us since the implementation of this process, there had been no further significant events relating to missed referrals, and referrals were audited regularly to confirm this.

The service always worked with people and healthcare partners to design, establish and maintain safe systems of care, in which safety was always well managed and monitored. They made sure there was always continuity of care, including when people moved between different services.

There were systems for processing information relating to new patients and the summarisation of notes. This was evidenced by the service having no records awaiting summarisation at the time of inspection. Clinical notes, including paper records, were consistently summarised on the same day they arrived. Monthly spot check audits were undertaken to monitor the timeliness and accuracy of this process. As a result, clinicians had immediate access to current patient records at registration, which promoted safe care, minimised the risk of errors, and allowed prescriptions to be issued promptly, enhancing outcomes for people who used the service. The service also used the NHS England ‘GP2GP’ system to transfer medical records electronically and securely when people changed services. This helped ensure clinicians had quick access to accurate and up-to-date information, supporting continuity and safety of care.

A remote review of the service’s clinical system indicated referrals and test results were being managed in a timely manner. There were established policies and procedures to support staff managing workflow, including tasks, referrals, coding and correspondence. An NHS-approved AI tool was introduced to support timely document management, helping staff process and summarise clinical records and identify the right codes. Administrators still had oversight of the clinical records and codes and followed a standard operating procedure for this. Monthly audits were undertaken to review workflow, document summarisation and coding accuracy. Any errors identified were addressed and if there were continued themes by a staff member this was then discussed with the individual involved, with anonymised lessons shared with the wider team to promote continuous quality improvement. The service had a structure in place to monitor and audit workflow and document processing in relation to staffing levels and factors that could influence delays, such as staff absence. This supported continuity of care by ensuring healthcare professionals had access to the most up-to-date information and could make timely interventions where needed.

There were systems in place for sharing information with staff and other agencies to enable them to deliver safe care and treatment. The service had processes to monitor delays in referrals and had clear oversight of all urgent suspected cancer pathway referrals (previously known as the 2-week-wait (2WW) pathway). This was evidenced by a spreadsheet to monitor each referral made and audited to ensure the person had been booked with the secondary care providers within the expected 28-day timeframe.

The service worked with other providers to deliver shared care and when people moved between services. The service was linked with other services within the primary care network and worked collaboratively to meet the needs of people using the service. The service worked in partnership with other providers to deliver joined-up care for people moving between services. Paramedics visiting people who were housebound collaborated closely with tissue viability nurses to provide prompt care and treatment. This teamwork enabled direct referrals and shared expertise, improving recovery and outcomes for people with complex or non-healing wounds and pressure ulcers.

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, relevant to their individual roles. There were designated safeguarding children and adult leads, with deputy and administrator roles, and staff knew who these were. A dedicated child protection plan policy was in place. This supported staff to recognise and respond appropriately to child protection concerns and reinforced the importance of effective communication between agencies. In September 2025 the service carried out a primary care self-assessment audit under Section 11 of the Children Act 2004 and the Care Act 2014. Findings were used to review and strengthen safeguarding practices, ensuring alignment with statutory guidance and continuous improvement in safeguarding arrangements.

Staff were able to describe the actions they would take if they had any safeguarding concerns or suspected a person was at risk of harm, including situations where regular services users appeared out of character. Safeguarding alerts were added to the service’s clinical record system when relevant, to ensure staff were aware of ongoing concerns and could act accordingly.

The service maintained a list of vulnerable people and acted on concerns working in partnership with other organisations. There were regular multi-disciplinary meetings where safeguarding concerns were discussed, which included involvement from external stakeholders where relevant, such as the health visiting team. Meeting minutes from such meetings were available for staff who could not attend.

There were safe systems and processes in place to ensure children had been appropriately followed up with when they failed to attend appointments, including secondary care clinic appointments. Chaperoning policies were in place and accessible to staff. A mixture of clinical and non-clinical staff members had chaperone responsibilities as part of their role. All staff members had completed Disclosure and Barring Service (DBS) checks and relevant training to ensure they would be appropriate to undertake this role.

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. The percentage of respondents to the national GP Patient Survey (2025) who stated ‘during their last GP appointment they were involved as much as they wanted to be in decisions about their care and treatment’ was 95%, which was above the local and national average.

Emergency equipment was available and maintained. The emergency trolley was well-stocked, and all items were noted to be in date. Staff could recognise when a person was deteriorating and knew what actions to take.

People were advised on risks related to their condition and actions to take if their condition deteriorated. For example, information on managing worsening symptoms was shared with people when they contacted the service, including signposting to emergency services. Safety-netting advice was provided during consultations with a healthcare professional.

The service had effective systems to respond to safety alerts, which was confirmed by remote searches conducted within the clinical system. Staff had access to a wide range of clinical tools and guidance to support people with long-term conditions, such as diabetes, hypertension, and respiratory diseases. People were routinely invited for health checks to help monitor and manage their wellbeing.

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. Electrical, gas and water testing had been undertaken regularly to ensure the environment was safe. Health and safety risk assessments and audits had been undertaken and risks identified had been addressed. Display screen equipment (DSE) assessments had been completed annually for staff members, and an overarching DSE risk assessment had been implemented to outline the requirement for annual self-assessments. There was a business continuity plan in place to support any major service disruptions, such as IT failures, which was monitored and reviewed.

Portable appliance testing and equipment calibration had been completed and monitored on a routine basis. Risks such as fire, hot water systems, and legionella were assessed and managed appropriately. The service had a fire evacuation plan and policy, and fire warden training had been completed by the appropriate members of staff. 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 well to provide safe care that met people’s individual needs.

There were a range of clinical and non-clinical roles within the service. Staff received training that was relevant and up to date. The service had processes to monitor and support staff development, ensuring everyone had equal opportunities to learn and progress. Leaders audited staff training monthly to check for compliance and sent a reminder to staff to complete any due or overdue modules. Records reviewed as part of this inspection indicated all staff were compliant with the service’s training expectations. Leaders invested in developing staff skills and promoting internal career progression, which helped to retain experienced team members. Staff consistently told us they felt supported and valued, and they had access to external training to enhance their knowledge and improve outcomes for people using the service.

Staff were working within their agreed areas of competence, and these were assessed and documented through annual appraisals and regular one-to-one meetings with the team leads. Staff received a structured induction tailored to their specific roles and responsibilities and included time for shadowing colleagues and meeting with line managers. Ongoing support was provided through regular supervisions and appraisals, with additional prescribing checks for clinical staff where required.

Regular, documented clinical supervision for non-medical prescribers took place in line with the service’s clinical supervision policy. The service also provided informal supervision opportunities through case-based discussions, group reflections and lunch-and-learn sessions.

Safe recruitment processes were followed. The provider’s recruitment and Human Resource (HR) records met the requirements of their policy and Schedule 3 of the Health and Social Care Act 2008. Our review of 3 staff files showed appropriate recruitment checks had been completed, and records were maintained accurately.

Staff told us there were sufficient numbers of staff to manage workloads effectively, which helped prevent backlogs of tasks and reduced the need for excessive working hours. Staff rotas were planned in advance, with oversight to ensure appropriate cover was in place when required. This meant if a clinician was absent at short notice, their pre-booked appointments could be reallocated into protected same-day slots with another clinician.

There were established and embedded processes for emergency cover, including support from clinicians and staff within the primary care network. Arrangements were in place to minimise the risk of lone working and ensure practice remained safe in emergency situations. A lone working risk assessment had been developed and was available to guide staff should such a situation occur.

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 (IPC) lead, and staff were aware of who this was and how to escalate any IPC concerns. All staff had completed relevant IPC training as part of their mandatory training programme, and feedback indicated they had a good understanding of IPC principles. Staff vaccinations were kept up to date in line with the latest UK Health Security Agency (UKHSA) guidance. Personal protective equipment (PPE) was appropriately stocked and accessible. Monthly compliance audits confirmed staff used PPE in accordance with the service’s IPC policy.

Spillage kits were available for use and staff had received training in handling specimens safely. All cleaning items used in the service had appropriate processes in place to control substances hazardous to people’s health. The service had clear processes for managing clinical waste. Waste was segregated correctly and disposed of safely in accordance with current waste management standards.

The service had a clear IPC policy which referred to relevant national guidance, such as the Health and Social Care Act 2008 Code of Practice. Records showed audits were completed according to the service’s schedule and actions were taken to address any issues identified. Risk assessments were completed, and actions taken to mitigate risks.

The facilities and premises were clean, and systems were in place to prevent the spread of infection. All staff cleaning logs were maintained on a daily basis, and supporting documentation verified there were no gaps in the records. Clinical equipment was maintained in a clean condition, with evidence of regular cleaning and auditing to monitor standards. Cleaning schedules were in place for the external cleaning company, however, at the time of inspection, there was no evidence available to demonstrate these schedules were being followed by the external cleaning company. This was discussed during the inspection, and the service immediately implemented a daily monitoring checklist. Evidence was subsequently provided to confirm this had been implemented in full by the cleaning company. We also noted the cleaning company carried out monthly audits and shared feedback with its staff to improve cleaning standards.

The service made sure medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

As part of our inspection, we carried out remote searches and reviewed samples of care records in the service’s clinical system. These searches showed medicines were being managed effectively, including appropriate monitoring for people prescribed high-risk medicines, in line with national guidance. The searches also demonstrated medication and long-term condition reviews were detailed and person-centred. Reviews were carried out in a structured way and considered the best interests of each person, including people with a learning disability.

Staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely. They followed protocols to ensure they prescribed all medicines safely, and ensured people received all recommended medicines reviews and monitoring. For example, all alerts received from the Medicines and Healthcare product Regulatory Agency (MHRA) (the national organisation responsible for ensuring medicines and medical devices are safe and appropriately dealt with) were managed and addressed in a timely manner. All MHRA alerts were shared across the primary care network to support a unified approach and ensure people received consistent and safe care across all services.

People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms. A random sample of reviews showed records contained sufficient clinical information to support safe prescribing and future care planning, including safety netting advice. The service had a system to manage recalls for high-risk medicine monitoring and evidence to demonstrate all clinical searches were run routinely.

Staff received regular training and felt confident managing the storage, administration and recording of medicines. For example, staff carried out and recorded daily fridge temperature checks as per the service’s policy. Records showed any temperature variations were identified, documented, and managed in accordance with national guidance to ensure medicines were stored safely. Medicines and medical gases, including oxygen, were stored safely. Staff carried out regular checks of stock levels and expiry dates for all medicines, including emergency medicines and vaccines.

Clinicians prescribed medicines appropriately to optimise care outcomes, including antibiotics. Prescribing data reviewed as part of our inspection confirmed this, for example, the number of antimicrobials issued by the service was in line with the local and national averages. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment. All Patient Group Directions (PGDs) and Patient Specific Directions (PSDs) were completed and up to date.Prescription stationery was logged and stored securely.