Willington 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 the same.

This service scored 62 (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 Patient Participation Group (PPG) felt the provider took concerns seriously and proactively made improvements to the service. Managers encouraged staff to raise concerns when things went wrong. Systems were in place to discuss, learn from and disseminate information from clinical issues or learning events. 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. Learning from incidents and complaints resulted in changes that improved care for others. For example, the use of technology to send information and booking links to patients; increase in ‘wellbeing’ meetings to promote engagement with colleagues and the different teams, and introduction of a supply of specimen bottles for reviews on the front desk so patients can help themselves.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

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

Multidisciplinary team meetings were used to raise awareness of potentially vulnerable groups of people. The service had systems in place to generate and corroborate the children’s register with health visiting services and relevant cases were discussed at the monthly meetings. There were systems in place to follow up people who failed to attend appointments in primary and secondary care or, were frequent attenders to the emergency department.

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. Systems were in place to check emergency equipment and medicines. The list of emergency medicines with expiry dates was held electronically. However, we found 3 medicines which had passed their expiry date. Most emergency medicines were stored in the doctor's bag so would therefore be unavailable when the bag was taken off site. Following our assessment the provider told us they planned to review the location of emergency medicines at the next partners meeting.

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 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.

A fire risk assessment had been completed, and staff completed online fire training and attended regular fire drills. A legionella risk assessment had been completed and required action as outlined in the action plan had been completed. Regular testing of water temperatures took place. Electrical and medical equipment had been tested and calibrated as required. 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. 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. Staff were positive about the support, training and development they received.

Safe recruitment practices were followed. However, not all of the information as outlined in Schedule 3 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 was available to view. For example, proof of identify including a recent photograph or documentary evidence of any qualification relevant to the duties for which the person is employed or appointed to perform. The provider immediately updated staff records with photographic identification as required.

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. Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks. The external cleaning company carried out regular audits to ensure the standard of cleanliness met the required standard. Clinical waste procedures were in place.

Staff vaccination was not always maintained in line with current UK Health and Security Agency (UKHSA) guidance if relevant to their role. Evidence of routine immunisations, such as tetanus, diphtheria and polio had not been recorded for all staff. Following our assessment the provider shared a risk assessment for immunisation of staff. The provider planned to ask staff to provide information about their immunisation status through documentary evidence and completing and signing a declaration. This work was due for completion by the end of June 2025.

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.

The service had effective systems to manage and respond to safety alerts and medicine recalls. However, for a number of people not all alerts had been fully adhered to. For example, not all patients prescribed a specific type of medicine for diabetes had been informed of the potential risks associated with this medicine. The provider took immediate action and sent information on associated risks to people prescribed this medicine. Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring. However, our clinical searches identified although most people received the recommended monitoring, this was not always consistent. For example, not everyone who received treatment following an exacerbation of their asthma had a follow up within 48 hours. Not all people prescribed medicine that was potentially additive had received an annual medicine review to ensure correct compliance, avoid overuse and monitor for side effects. Our clinical searches also identified potential missed diagnosis of kidney disease for a number of people. Immediately after our assessment the provider forwarded an action plan to address these issues.

Patient Specific Directions (PSDs) for the nursing team to deliver vitamin B12 injections were not in place, and we found evidence that these injections had been administered without a PSD in place. The lead nurse had identified this issue and had undertaken quality improvement activity and developed a Standard Operating Procedure (SOP), which had been agreed and signed off. Following our assessment the provider shared the SOP and told us the process would be implemented the week following our assessment, with the duty doctor responsible for generating the PSD within the patient record.

Prescription stationery was stored securely. However, the system in place for tracking prescription stationery did not tally. There was a system for recording when prescriptions are taken out of the box. Staff were not aware of the sequencing of prescription stationery. In addition, the 1st and last number of a new prescription pad had been recorded on receipt, but staff had not recorded the number of the prescription when used. The service immediately updated the record for the prescription pad.

Staff regularly checked the stock levels for all medicines, including emergency medicines and vaccines. 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.

Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes. The pharmacy team supported medicine reviews for people with co-morbidities and polypharmacy. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.