Horndean 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.

At our last assessment, we rated this key question as Good. At this assessment, the rating remains 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 proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. People felt supported to raise concerns and felt staff treated them with compassion and understanding. Representatives from the service’s patient participation group (PPG) felt the service 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 felt there was an open culture, and safety was a top priority. The service 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. Learning from incidents and complaints led to improvements in care. For example, a person came to collect a letter however the wrong letter was handed to them. They returned the letter unopened. The matter was promptly addressed, and staff were reminded of the importance of checking 2 pieces of identification and referring to the full name on the letter rather than just the initials, as per the service’s existing policy. The service undertook annual evaluations of complaints and significant events, to identify any themes or trends.

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 for processing information relating to new patients. At the time of the onsite visit, there was only 1 person whose records were waiting to be added to the system. The service worked with other providers to deliver shared care and when people moved between services. Referrals and test results were managed in a timely way. At the time of the onsite visit, only 4 pathology reports were pending review, all of which had been received that morning, with the clinicians. prioritising the review of results each day. The service’s administration team reviewed the suspected cancer referrals (formerly known as the 2‑week wait pathway), and these were all managed in a timely way and monitored on a daily basis.

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 available and known to staff, who were appropriately trained in safeguarding procedures and at the time of the onsite visit, all staff were compliant with safeguarding training requirements relevant to their role. The service maintained a list of vulnerable people and acted on concerns, working in partnership with other organisations.

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 accessible and well-maintained. Staff could identify deteriorating people and responded quickly when immediate medical attention was needed. People were advised on risks related to their condition and actions to take if their condition deteriorated. Reception staff also had access to a ‘purple folder’ which held information about safety-netting advice should a person contact the service describing certain symptoms, for example, sepsis guidance.

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. Health and safety risk assessments and audits had been undertaken and risks identified had been addressed. For example, there was a health and safety risk assessment and legionnaires water test completed December 2025.

Fire drills were held twice yearly and all staff had completed their fire safety training. Fire extinguishers were noted to have been checked in the past year. There was a business continuity plan which was monitored and reviewed.

The service used an external cleaning company. Daily cleaning records were not available during our onsite visit, but the service quickly provided them post-visit and confirmed these would be kept onsite going forward. The cleaning company and the service’s IPC lead met monthly to discuss and address any shortfalls in cleaning.

Control of Substances Hazardous to Health (COSHH)materials were checked and the data sheets correlated with the cleaning products held in stock.

Portable Appliance Testing (PAT) stickers were visible on all electrical items and these had last been tested in April 2025.

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 Safe recruitment procedures were followed, ensuring all new staff underwent appropriate checks. While not all staff had DBS checks, risk assessments were carried out for these staff, reviewed annually, and self-declarations were completed at the same time. Although health questionnaires were missing from 5 staff records, the service promptly addressed this and confirmed immediate implementation after our onsite visit. Following recruitment, staff progressed through a comprehensive induction process, supporting them as they entered their respective clinical or non-clinical roles within the service. Staff training was noted to be up to date, with learning needs and development managed appropriately to ensure that everyone worked within their agreed areas of competence. The service held specific timeslots for clinical supervision meetings twice weekly, and all relevant clinical supervision had been completed. Supervision and appraisal arrangements were robust, supporting ongoing professional development and ensuring high standards of practice were maintained throughout the service.

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 had relevant training. The external cleaning company held monthly meetings with the service to ensure cleaning was meeting the expected standard, including the use of different coloured cloths and mops to ensure the premises and equipment were kept clean.

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.

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. 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. Staff followed protocols to ensure they prescribed all medicines safely, and ensured people received all recommended medicines reviews and monitoring. Medicines, including controlled drugs were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines, vaccines, and controlled drugs. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments. The service had effective systems to manage and respond to safety alerts and medicine recalls. Clinical searches completed also confirmed that the service adhered to this process. Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring. For example, by conducting a series of remote clinical searches and records reviews, we noted all asthmatic people who had been issued an inhaler in the past 12 months had been reviewed and had received the relevant monitoring and follow ups. Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. Prescribing data reviewed as part of our assessment confirmed this. For example, the number of antimicrobials issued was in line with local and national averages.

Fridge temperatures were monitored daily, and there was a clear process to manage any temperature breaches. Temperature checks were consistently documented, and staff were aware of the procedure to follow should readings fall outside the recommended range.

All Patient Group Directions (PGDs) and Patient Specific Directions (PSDs) were in place and up to date. The service had a monitored prescription process with designated staff, but we noted there was a gap in the monitoring of returned blank prescriptions at the end of the day. Returned prescription numbers were not logged, so accountability could not be confirmed as per NHS counter Fraud guidance. This issue was discussed with the service, which acted promptly to address the issue. Since our onsite visit, the service has provided evidence to confirm a risk assessment will be conducted and the process reviewed.