Bryn Cross 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 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 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

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.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

The service did not always detect and control potential risks in the care environment as we noted that risk assessments were out of date or not in place including fire safety and legionella. The gas boiler was outside of its recommended servicing interval. After the inspection the practice sent us an up to date fire risk assessment and a gas safety certificate. A legionella risk assessment had also been scheduled in to be completed.

Fire evacuation drills were not being completed, and the testing of emergency lighting was being completed every six months which was not in line with fire safety guidance which advises monthly testing. The practice informed us after the inspection that they had completed a fire drill.

The practice had emergency medicines in place, but we found that during the inspection the practice did not have aspirin in place. The practice informed us after the inspection that this had now been purchased.

The service had a business continuity plan which was regularly and outlined how the service should continue to operate in the event of a disruption.

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.

The service employed a range of clinical and non-clinical roles, which included GPs and nurses. Leaders ensured staff were up to date with their training which the service had deemed mandatory and operated within their agreed areas of competence. The service followed safe recruitment procedures when employing staff, which was in line with national legislation. This included identity checks, review of qualifications, obtaining of professional references and a criminal records check.

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. However we identified some areas for improvement.

The service had cleaning schedules available, which outlined how staff should clean the building and its equipment but the practice did not have an appropriate mop for cleaning the clinical rooms, and we noted that clinical waste bags were not appropriately labelled. After the inspection the practice informed us that a mop had been purchased and the clinical waste policy updated.

During our onsite visit, the service's premises and a sample of equipment reviewed was noted to be visibly clean. The service’s infection prevention and control lead conducted regular risk assessments and audits to ensure compliance and took action where necessary to mitigate any identified risks. Staff had completed relevant training in infection prevention and control.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.