Triangle 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 requires improvement. At this assessment, the rating has changed to Good.

The service had a good learning culture and people could raise concerns. Managers investigated incidents thoroughly. People were protected and kept safe. Staff understood and managed risks. The facilities and equipment met the needs of people, were clean and well-maintained and any risks mitigated. (However the practice had a lift which had not been working since the last inspection, the practice informed us parts were no longer available for the lift and they hoped to be moving. The practice had undertaken a risk assessment and planned clinical rotas carefully to ensure patients with mobility issues could be seen on the ground floor). There were enough staff with the right skills, qualifications and experience. Managers made sure staff received training and regular appraisals to maintain high-quality care. Staff managed medicines well and involved people in planning any changes.

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.

At the previous inspection we found that the practice provided a significant events log, however the log lacked detail and there were no dates recorded for when the significant events took place and no documented evidence of learning outcomes. During this inspection we found the handling of significant events was appropriate. Documentation review showed the practice was having regular meetings where significant events and lessons learned were discussed.

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. The significant event policy was kept on the shared drive which all staff could access.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. Managers encouraged staff to raise concerns when things went wrong. The practice held monthly practice meetings during which, the whole team discussed and learnt from issues.

Staff felt 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. At the previous inspection we found that not all complaints were recorded, and verbal complaints were resolved verbally at the time they were made. There was no evidence of learning from complaints being used to drive continuous improvement and the complaints log provided by the practice lacked detail. At the most recent inspection the practice had received 18 complaints in a 12 month period, during this inspection we reviewed 2 complaints in detail and found they had been satisfactory responded to. We saw a comprehensive complaints log and a complaints policy that had been reviewed in March 2025. We were told a complaints log was kept at reception and themes were discussed every month as complaints was listed as a standard agenda item.

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. The service worked with other providers to deliver shared care and when patients moved between services. The practice told us the patient management system was cleared daily; the operations manager had been trained and was responsible for processing all new registrations.

Referrals and test results were managed in a timely way. All clinical staff did their own referrals, the practice kept a register and checked that all patients had appointments, if any appointments needed to be booked, the operations manager over saw that everything was done correctly. In addition, the practice conducted a weekly audit.

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.

At the last inspection evidence provided by the practice showed that one clinical staff member and one non-clinical staff member had not completed the required level of children’s safeguarding. Also out of hours were not routinely informed of relevant safeguarding information but could access the practice clinical record systems. At this inspection we found all staff (clinical and non-clinical) were up to date with training and had completed the level required.

Since the last inspection it was practice procedure to ensure patients were coded appropriately for safeguarding and an alert mechanism requiring approval was now in place information to be shared 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.

Data from the GP Patient survey 2025 showed a total of 91% of respondents were involved as much as they wanted to be in decisions about their care and treatment during their last general practice appointment. This was in line the local average of 92% and national average of 91%. During this assessment we received feedback about the practice. None of the respondents gave negative feedback about their level of involvement in decisions about their care and treatment.

Emergency equipment was available and maintained in line with guidance. Equipment was located in an accessible place and all staff were aware of where it was kept. The practice was set out over 3 floors, and equipment was kept on the middle floor in the nurse’s room.

At the last inspection there was no quick reference guide for receptionists to identify a deteriorating or acutely unwell patient or suspected sepsis over the phone or at reception. At this inspection we saw there was a poster at reception explaining what signs staff should look out for with a deteriorating or acutely unwell patient. We also saw the practice had implemented a reception clinical navigation tool, which was comprehensive and clearly outlined specific conditions, details, the type of service/appointment required. All staff had completed sepsis training.

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.

At the previous inspection an outstanding action was the out of service lift. At the time the practice told us that they had no plans to repair the lift as they hoped to be moving premises in the near future. The practice told us that patients unable to use the stairs would be seen in the one clinical room on the ground floor, however it was not clear that all risks associated with the lift being out of order had been considered.

At this inspection the lift was still out of use, the practice explained the parts for the lift were obsolete, and they still intending to move, however their application to the ICB (Integrated care bored) had been rejected. The nurse explained comprehensively what steps the practice took to aid patients with mobility issues in terms of prioritising and seeing patients on the ground floor, alerts were put onto patients’ records. The practice also showed us a risk assessment reviewed in July 2025, which corroborated what the nurse had explained to us.

At the last inspection the Portable Appliance Testing (PAT) report was not clear and did not have a clear date that testing had been carried out. The fire risk assessment identified some areas of concern including areas of high risk. We saw no evidence of testing of smoke detectors/alarm systems or emergency lighting was being carried out.

At this inspection we saw a certificate for PAT testing equipment dated June 2025. We saw fire safety risk assessments were done every 2 years, the lead GP and operations manager were fire marshals, weekly fire alarm checks were done, and fire drills were done every 6 months. An external company had undertaken a fire risk assessment July 2025 and had identified low risk items for the practice to action; these had not been actioned at the time of the inspection and the practice had set themselves a 6 month target for completion.

Contracts were in place to ensure the premises were maintained. Health and safety risk assessments and audits had been undertaken. There was a business continuity plan in place which was monitored and reviewed.

At the previous inspection there were gaps in staff recruitment files, so we were not assured that the practice was following safer recruitment practices. During this inspection we saw that safe recruitment practices were followed. We reviewed 5 staff records which demonstrated the practice was following safer recruitment practices and had collected all relevant documents.

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 practice. 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.

At the last inspection the training log provided by the practice showed gaps in equality and diversity training for three clinical staff members. At this inspection all staff (clinical and non-clinical) had completed equality and diversity training.

At the last inspection the practice told us that there was no formal process in place for reviewing the performance of locum GPs and non-medical prescribers, but that informal supervision took place. At this inspection we were told that the Healthcare assistant (HCA) had quarterly competency reviews, also an annual review, they made this process more formalised and every day they had peer review and discussed cases. On recruitment they used a reputable agency which had good vetting procedures, which included induction checklist and skills checklist with mandatory training, this was one method they used to ensure that all the locums were up to date, as well as ongoing internal processes.

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. Risk assessments and audits were completed.

At the last inspection we found that actions from the Infection prevention and control audit had been identified, only some actions had been completed. At this inspection an infection control audit was undertaken by NHS England in October 2024 the practice had achieved 100%. The cleaners had a cleaning schedule and check list of what needed to be completed at each visit. We saw cleaning schedules that were signed and dated.

At the previous inspection we found that the review of patient records indicated that medicines safety alerts were not always actioned in a timely manner. During this assessment we found that the provider had effective systems to manage and respond to safety alerts and medicine recalls.

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.

At the previous inspection we found that receipt and issue of blank prescription stationary was not being recorded. At this inspection staff told us about the system used for blank prescriptions. All prescriptions were removed from clinical rooms daily and locked away in a secure cupboard, a folder was now in place where records of prescriptions were documented, signed and dated and could be clearly tracked and traced.

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. Waste medicines were recorded and disposed of appropriately including medicines returned by patients. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments.

At the last inspection alerts were not being actioned in a timely manner and patients’ medication had been changed without the patient being informed prior to the change. At this inspection we found the practice had effective systems to manage and respond to safety alerts and medicine recalls alerts had been processed in a timely manner and patients had been contacted as required.

Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring. There were suitable processes for staff to follow when dispensing medicines (dispensing practices). 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 by the provider was lower than local and national averages. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.