Wellspring 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 rated this key question as good. This meant safety was a priority, and people were protected from abuse and avoidable harm.

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 were supported to raise concerns and staff treated them with compassion and understanding. Representatives from the Patient Participation Group (PPG) felt the service took concerns seriously and proactively made improvements to the service.

The service held clinical and administrative learning event meetings where positive care and near miss events including clinical issues were discussed and learnt from. Information was disseminated to those who were not present at the meeting.

We found that complaints were regularly reviewed to identify trends and that when it was appropriate to do so, learning was shared with staff. Staff felt there was an open culture, and that safety was a top priority. 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, a person incurred a delay in their referral being generated and forwarded to specialist clinic. The service fully investigated the concern and made chances, including targeted refresher training to reinforce expectation around communication, documentation, and referral processes. Internal procedures were reviewed to ensure clearer accountability and escalation pathways for clinical actions. The learning from this complaint was shared with the wider team to promote reflective practice and reduce the risk of similar issues occurring in future.

Leaders encouraged staff to raise concerns when things went wrong. There was a system in place for staff to report incidents, near misses and safety events the service referred to these incidents as significant events. Significant events that had occurred within the practice were investigated, discussed with staff at team meetings and learning disseminated to improve the service provided. Information was shared to those who were not present at the meeting. The service reviewed all significant events to identify trends and themes and ensured that relevant changes were made to reduce reoccurrence of the events. There was a comprehensive significant event policy in place which was available to all members of staff. We saw evidence of a training process and that significant events were regularly reviewed and learning shared with the relevant staff. We reviewed two significant events and found that a thorough investigation had been completed, and changes had been implemented to avoid issues occurring again that the effectiveness of the changes made was reviewed.

The service worked with people and partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured, ensuring continuity of care, including when people move between different services.

The service had a referral policy which included guidance for the management of two-week-wait suspected cancer referral pathway.

The service utilised hospital advice and guidance pathways obtaining advice from specialist consultants both prior to a referral or guidance in place of a referral to obtain a speedier treatment options for the person.

Specialist referral templates were utilised which required tests and investigations to be carried out prior to a referral being made. For example, certain specialist consultants required blood tests, x-rays or scans to have occurred prior to a referral being made.

Information was provided to people regarding a referral. For example, information was provided when a two-week suspected cancer referral was initiated by the service.

The service audited referrals to monitor that a person had received an appointment. For example, the medical secretaries checked to make sure that a person referred for a two-week wait suspected cancer referral received an appointment within the required timeframe and followed up if an appointment had not been allocated.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. People felt supported and that clinicians acted in their best interest to keep them safe. The service shared concerns quickly and appropriately.

The service had a clear focus on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They shared concerns quickly and appropriately.

The practice’s safeguarding policy included all aspects of the statutory framework, to include female genital mutilation (FGM), radicalisation and due regard to the need to prevent people from being drawn into terrorism, modern slavery and human trafficking. Clinicians we spoke with were aware of safeguarding and specifically talked about how they respond to potential concerns about FGM.

Staff were appropriately trained in safeguarding procedures. There was a dedicated safeguarding GP lead, deputy GP lead, administrator and regional safeguarding lead who worked with the provider to support the service. The service maintained a list of vulnerable people and acted on concerns working collaboratively with other organisations. Multidisciplinary team meetings were regularly held and used to raise awareness of potentially vulnerable groups of people. Practice GPs, nurse manager and health visitor attended the safeguarding meetings. All staff members we spoke with were aware of who the lead safeguarding leading was and how to raise a safeguarding concern. Flow charts to communicate routes to raise safeguarding concerns were available in all clinical consulting rooms.

There were systems in place to follow up people who failed to attend important health care appointments, for example, childhood immunisations or were frequent attenders to the hospital emergency department. The GPs provided intelligence for case conference meetings, for example, in respect of child criminal exploitation and used their wider knowledge of families and communities to inform these meetings.

People were offered chaperones for intimate examinations or procedures, for example, breast examinations. Staff had received training on chaperoning and had a clear understanding of their role.

The service worked with people to understand and manage risks using a holistic approach. The service provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The practice had engaged with people to obtain their views on access to a health care professional. The service engaged with their Patient Participation Group (PPG) and held an event to communicate change to their appointment booking system.

Results showed that people were mostly satisfied with access. National GP Patient Survey data and feedback received from people reflected that 69.9% of people responded positively to the overall experience of contact with their GP practice with the national average being 75.4%. These percentages are within tolerances of the national average satisfaction percentage.

There were systems and processes in place to identify and manage emerging risks of people and regular liaison with other health care professionals to highlight the risk, e.g. with the community nursing team, palliative care team and referral to hospital consultants.

The surgery premises were owned by Nottingham city council and were leased from, managed and maintained by NHS property services. Health visitors, school nursing, midwives, specialist community services were located within the building. The service was located on the first floor within a multi designated building. For example, diabetic and respiratory nurse specialists, library, SureStart, city council and Nottingham city housing services. The council were responsible for the oversight of all risk assessments and cleaning arrangements. The practice had clear security arrangements to keep people and staff safe and access to non-public areas were adequately restricted and monitored. A lift was available for people who could not access the practice using the stairs.

We saw that the service had effective systems to monitor and comply with mandatory risk assessments, including fire safety and legionella testing to ensure that people and staff remained safe.

Records showed fire alarms were routinely tested, and the service had appointed fire marshals to direct people and staff in the event of a fire. Staff completed fire training and attended regular fire drills which included the evacuation of people.

Electrical equipment had been calibrated and tested. Safety alerts relating to equipment were shared with the relevant staff and acted on.

We observed that the practice was accessible for all people and included space for wheelchairs and prams. Hallways and corridors were clean and tidy and free from clutter. Staff offices were secure, and access restricted by electronic key-fobs.

Systems were in place for checking and monitoring emergency equipment and medicines. The practice kept recommended emergency medicines and equipment, including oxygen, and defibrillator. All staff had been trained in basic life support. Staff could recognise a deteriorating person and knew the action to take. People were advised on risks related to their condition and the actions to take if their condition deteriorated.

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. 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.

Staff received appropriate training and told us they were supported to develop and progress within the team. The service had access to additional staff employed through their primary care network (PCN). Processes had been established to ensure staff working for but not directly employed by the service were recruited safely, had received appropriate and up to date training and were working within their agreed areas of competence. For example, a pharmacist. social prescriber and GP Assistant.

The service assessed and managed the risk of infection. They detected and controlled the risk of infection spreading and shared concerns with appropriate agencies promptly.

There were systems in place to assess and manage the risk of infection. The practice ensured staff received immunisations appropriate for their role, in line with national guidance.

Infection, Prevention and Control (IPC) audits had been completed. There was a designated IPC nurse lead who had oversight, and staff were aware of who the IPC lead was. Staff had received relevant training. Risk assessments and audits were completed, and action plans were in place to mitigate potential risks. For example, an IPC audit was carried out in November 2024 and concerns which related to the building were reported to the City Council to action. These concerns were mainly regarding superficial cracks and chips of the decoration. At the time of our assessment these actions remained outstanding.

We saw evidence that clinical rooms were checked daily for cleanliness and equipment was cleaned after each use. Daily room checks and cleaning tasks were recorded at the end of each clinical session and retained for auditing purposes. For example, blood pressure cuffs were wiped with antibacterial wipes before being used on another person and cleaning of surfaces after each person. The infection control lead at the service carried out spot checks of all clinical areas to ensure compliance of infection prevention and control.

Disposable curtains were available is all clinical rooms which were recorded with a diary date for when they needed to be changed. Medical couches were all in good state of repair and were visibly clean with disposable couch rolls for use between each person.

The service used disposal single use equipment at all times and records showed that equipment was appropriately disposed of after use. For example, cervical cytology speculums. Clinical waste procedures were in place.

Cleaning staff were contracted by Nottingham City Council. Cleaning cupboards were visibly clean and single use equipment was used. For example, disposable colour coded mop heads and cloths. Cleaning logs were completed and retained for audit purposes and overseen by the IPC lead at the service.

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.

Clinicians 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 from their medicines. Staff followed protocols to ensure that all medicines were correctly prescribed and ensured people received recommended medicine reviews and regular monitoring. Protocols effectively supported the safe prescribing of medicines and staff involved people in reviews of their medicines.

Medicines were prescribed appropriately to optimise care outcomes, including antibiotics. Prescribing data reviewed as part of our assessment confirmed this. For example, data on antibiotics prescribing for the treatment of uncomplicated urinary tract infections showed the practice performance was within national averages relating to safe prescribing, and they had consistently done so since 2018.

Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring. For example, prescribing of pregabalin or gabapentin which are medicines used for the management of pain in long term conditions. Prescribing rates of these medicines were in line with national averages for the period from October 2024 to end of March 2025. Regular medication reviews were completed to monitor compliance and check ongoing suitability of the prescribing.

Prescribing of hypnotic medicines used for treating severe insomnia and interferes with normal daily life were in line with national averages.

We did not identify any concerns as part of our review of medicines. We reviewed the medical records of people who had a confirmed diagnosis of asthma and had received treatment for an exacerbation of their asthma symptoms in the last twelve months. The review found that people had all received appropriate treatment. However, we also found that four people we reviewed had not received a follow up of their asthma condition within required timescales, as stated by National Institute of Clinical Excellence, (NICE). As a result of our review, the service informed us that they would arrange formal follow ups for all people who received treatment for exacerbation of their asthma within the required timeframe.

We also reviewed a sample of records for people who were prescribed medicines for hypothyroidism, (underactive thyroid). We found there was an effective system in place for inviting people for reviews and regularly following up people who did not attend for reviews.

Recall processes were robust and demonstrated that people’s safety was a priority. The practice utilised varied methods of communication tools to contact people, including, text messaging, phone calls, letters and telephone calls. The service used interpreters when required.

Systems were in place to manage and respond to Medicines and Healthcare Products Regulatory Agency (MHRA) alerts and medicine recalls. Systems for managing the prescribing of medicines and treatment of other medicines were safe and met people’s needs.

Systems were in place for checking the stock levels and expiry dates of all medicines, including emergency medicines and vaccines. Medical gases, such as oxygen, were stored securely and safely and they had completed required safety risk assessments. Prescription stationery was stored securely and tracked throughout the practice utilising a robust process which all staff were aware of. Prescriptions in printer drawers were stored securely overnight.

Waste medicines were disposed of appropriately including medicines returned by people.