Practice Plus Group Surgical Centre, Devizes

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

At our last assessment we rated this key question good. At this assessment the rating has remained the same. This meant people were safe and protected from avoidable harm.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

The evidence showed a good standard. The centre 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 service promoted a positive learning culture through its implementation of the Patient Safety Incident Response Framework (PSIRF). Staff had access to the organisation’s Patient Safety Incident Response Plan (PSIRP), which set out a structured approach to responding to patient safety incidents with a clear focus on learning rather than blame. Incident responses were undertaken to understand contributory factors, identify opportunities for system-wide improvement and reduce the risk of recurrence.

A patient safety incident response policy was in place to support the principles and requirements of the Patient Safety Incident Response Framework (PSIRF). The policy outlined the organisation’s commitment to fostering a culture of openness, reflection and continuous learning.

The policy also set out how patient safety incidents and emerging safety concerns would be used as opportunities for learning and improvement. This approach aimed to strengthen systems and processes, improve practice, and enhance the quality and safety of care for people using the centre.

Leaders investigated incidents and took action to share learning across teams and the wider centre. Learning from incidents, themes and investigations was routinely discussed through daily huddles, weekly meetings and monthly governance meetings. This supported organisational learning, encouraged staff engagement with patient safety and helped embed improvements in practice to reduce the risk of similar incidents happening again.

The surgical centre fostered a learning culture through joint clinical governance meetings with its sister hospital. These meetings enabled the sharing of learning, patient safety information and best practice across both sites. We reviewed meeting minutes from March 2026 which showed discussions relating to patient safety incident responses, patient safety investigations and the application of the duty of candour. This demonstrated that learning was not only reviewed locally but also shared more widely to inform service improvements and enhance patient safety across the organisation.

In addition, flash alerts were disseminated across all services within the organisation, outlining lessons identified from incidents and the actions taken in response. This supported the consistent sharing of learning.

All staff knew what incidents to report and how to report them. Staff told us feedback from incidents was communicated via email and meetings. 

Staff described a positive learning culture in which they were encouraged to report and escalate incidents. 

For example, staff told us about an incident where a patient was discharged with the incorrect take-home medication (TTO) following preparation by the in-house pharmacy. The error was identified immediately after discharge, and the patient was contacted and asked to return to the centre. The correct medication was provided, a duty of candour process was completed, and the incident was reported through the organisation’s incident reporting system. Learning from the incident was shared with the wider team, reinforcing the importance of checking every patient prescription before discharge to improve medication safety and prevent similar incidents in the future.

Leaders told us the service held regular mortality and morbidity (MM) meetings and learning from these meetings was shared with staff. However, not all staff we spoke with were aware of the MM meetings or the learning arising from them. This meant opportunities to consistently embed learning from MM and disseminate good practice across the centre were not always fully realised.

The evidence showed a good standard. The centre 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 centres.

The service had established clear referral, admission and discharge pathways to support the delivery of safe and coordinated care. Referrals received through the NHS e-referral centre and other approved routes were reviewed against agreed clinical acceptance criteria before appointments were arranged, ensuring patients were only accepted where their needs could be safely met.

Patients were contacted promptly following referral and progressed through clearly defined assessment, pre-operative and surgical booking processes. Patients were only listed for surgery when there was a clear clinical indication, they were medically fit for treatment, and willing to proceed. Where patients were not suitable for surgery, arrangements were made for ongoing monitoring or referral back to their GP.

The service did not have overnight facilities. Patients requiring an overnight stay or ongoing inpatient care were transferred to their sister hospital through established transfer arrangements, supporting continuity of care and ensuring patients could access the level of care they required.

The service worked collaboratively with its sister hospital by sharing standard operating procedures (SOPs), including an access and waiting list management SOP. This provided staff with clear guidance to support effective management of patient pathways, waiting lists and access to treatment. The shared approach helped ensure patients received timely care, supported the delivery of safe and consistent pathways, and enabled patient needs and expectations to be met.

Staff worked with relevant healthcare centres to ensure continuity of care throughout the patient journey and following discharge. Processes were in place to manage patients who did not attend appointments, including follow-up contact and communication with referring clinicians where treatment was no longer required. The centre also had SOP to manage patient and provider-initiated cancellations, rebooking arrangements and waiting list management, supporting timely access to care and reducing the risk of delays or gaps in treatment.

Regular scheduling meetings were also undertaken to review bookings and cancellations and confirm that all essential patient information had been received. This enabled staff to assess whether a patient’s needs could be safely met before treatment was scheduled. During the inspection, we observed a scheduling meeting where staff and leaders discussed upcoming surgical procedures, identified equipment requirements and potential concerns, and reviewed arrangements for a patient who required additional support. This demonstrated a proactive approach to planning care and managing risks within patient pathways.

The service had effective systems to support safe and coordinated patient pathways. For patients with complex needs, multidisciplinary team (MDT) discussions involved relevant services to plan and coordinate care. A shared high-risk patient spreadsheet was used by the senior nursing team to support effective communication and oversight of patients requiring additional support. This ensured individual care needs were identified and staffing, treatment and discharge arrangements were planned and actioned appropriately.

Discharge processes were structured and consistently followed. Patients were not discharged out of hours and received verbal and written information about their ongoing care, medications and follow-up arrangements before leaving the service. Key information, including the timing of last medication doses and venous thromboembolism (VTE) prophylaxis requirements, was reviewed and communicated to support continuity of care. 

The evidence showed a good standard. The centre 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 centre shared concerns quickly and appropriately.

The centre had safeguarding arrangements to protect people from abuse, neglect and avoidable harm. Experienced safeguarding leads based at the sister hospital site provided safeguarding advice, support and oversight for both hospitals. To strengthen local safeguarding provision, the centre was establishing a dedicated safeguarding lead trained to Level 4 safeguarding. This role would provide local expertise and leadership, support staff and visiting professionals, and help ensure safeguarding concerns were identified, escalated and managed.

The organisation had up-to-date safeguarding adults and children policies which provided staff with clear guidance on their responsibilities and the processes to follow when safeguarding concerns were identified. Policies supported the delivery of effective safeguarding arrangements and promoted a consistent approach to safeguarding across the organisation.

Staff understood how to recognise adults and children who were at risk of, or experiencing, abuse or harm. They were aware of their responsibilities to work in partnership with other agencies to safeguard people and had access to a safeguarding flowchart that outlined the actions to take when concerns were identified. This included contacting local adult protection teams or safeguarding services in the area where the patient resided.

The organisation had a secondary care restraint policy that promoted a person-centred approach to care, minimised the use of restrictive practices and supported staff to manage behaviours that may challenge in the least restrictive way possible. The policy provided a framework for balancing individual rights, safety and wellbeing while reducing the risk of harm.

Staff received safeguarding training appropriate to their roles. Staff were trained in safeguarding adults and children at Levels 1 to 3. Training records showed compliance rates of 100% for safeguarding Level 1 and 90% for safeguarding Level 3 training, supporting staff to handle safeguarding concerns effectively.

The evidence showed a good standard. The centre worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The centre involved people in managing risks throughout their care journey. Patients underwent comprehensive pre-operative assessments, during which individual risk factors, co-morbidities and support needs were identified and discussed. Staff worked with patients to develop personalised peri-operative care plans and involved them in decisions about their treatment, optimisation requirements and post-operative support. Patients with obesity-related risks, including obstructive sleep apnoea, were assessed and provided with information to support informed decision-making and risk management.

Systems and processes were in place to support the safe management of patient pathways and ensure risks were identified and addressed in a timely manner. Daily huddles were held to ensure staff were prepared to respond to any resuscitation event, identify potential issues with equipment or processes, and reinforce key safety learning.

The service had effective processes to identify and monitor risks. Weekly scheduling meetings were held to identify patients who required enhanced planning and support, enabling staff to make arrangements in advance of admission. This included planning for increased observation, suitable bed allocation and staffing levels to meet individual needs.

Effective risk assessments and action planning were undertaken throughout patients' care. Staff completed and reviewed risk assessments relating to falls, pressure ulcers, nutrition and hydration, and monitored these regularly. We reviewed patient records and found completed falls risk assessments and national early warning score (NEWS2) documentation. Venous thromboembolism (VTE) risk assessments were also completed and monitored in line with best practice. Staff told us patients were reviewed regularly throughout the day, with symptoms, medicines and risk assessments updated to reflect any changes in needs or condition.

The centre used an electronic bed allocation tracker and bed board to communicate key risks and individual care requirements to the multidisciplinary team, including physiotherapy and pharmacy staff. This supported coordinated care planning and helped ensure patients were cared for in the most appropriate environment. Where appropriate, carers were involved in care through John's Campaign, helping to ensure risks were managed collaboratively and care was tailored to individual needs. John's Campaign is a British initiative advocating for extended visiting rights, allowing family carers to stay with patients who have dementia or complex needs in hospitals and care settings without normal time restrictions.

Staff had access to policies and guidance to support the management of clinical risks. The centre shared a management of the deteriorating patient policy with its sister hospital, providing staff with clear guidance on the actions required when a patient's condition deteriorated. Staff also had access to a sepsis policy, which outlined the assessment and management of patients with suspected or confirmed sepsis.

Staff received training appropriate to their roles and responsibilities to support the identification and management of risks. Nurses were trained in immediate life support (ILS) and healthcare assistants were trained in basic life support (BLS), helping to ensure staff could recognise and respond to deteriorating patients and medical emergencies.

The centre had arrangements to support organisational oversight of risks. Monthly risk review meetings were held to monitor risks and oversee mitigation plans. We reviewed the April 2026 risk review meeting minutes, which identified generator failure, a blood fridge being out of use and potential delays in reviewing histology results as the highest risks facing the centre. Leaders had implemented actions to mitigate these risks, and evidence showed that identified issues had been addressed or were being actively managed, providing assurance that risks were reviewed, escalated appropriately and progressed towards resolution.

The centre also used mortality and morbidity (MM) meetings as a mechanism for identifying, reviewing and managing risks. These meetings were held bi-monthly and chaired by the medical director. Leaders told us individual specialties also held their own MM meetings, with learning and key themes shared during clinical governance days to support the dissemination of learning and ensure risks were identified, discussed and acted upon across the organisation.

The evidence showed a good standard. The centre detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The centre provided a clean, well-maintained environment that was suitable for the delivery of safe care. During the inspection, we found clinical and non-clinical areas to be clean, tidy and free from clutter. The main waiting area was spacious and contained sufficient seating for patients and visitors. Accessible facilities were available, including a wheelchair-accessible toilet, and patients had access to hot and cold drinks while waiting.

The environment met relevant standards and was supported by systems to manage infrastructure and environmental risks, including water, waste and ventilation systems. Equipment was visibly maintained and fit for purpose. We saw portable appliance testing (PAT) stickers on equipment, confirming that electrical safety checks had been completed and were in date.

The centre had effective processes to maintain fire safety. Monthly fire door inspections were completed across departments, and records from January 2026 to May 2026 demonstrated that all required checks had been undertaken. Monthly emergency lighting tests and fire extinguisher checks were also completed, providing assurance that fire safety systems and equipment were maintained and available for use in an emergency.

Environmental risks were monitored and managed appropriately. The centre carried out monthly water temperature monitoring, with tap temperatures routinely checked and recorded to reduce the risk of waterborne infection and ensure compliance with safety requirements.

The centre had suitable decontamination arrangements for surgical and anaesthetic instruments and devices. A sterile services department procedure manual, last reviewed in June 2024, provided staff with guidance on decontamination processes, including the control of specifications, hygiene requirements, instrument collection and cleaning procedures. The manual clearly defined responsibilities and standardised processes to support safe practice.

Healthcare environmental risk assessments were completed to identify and mitigate risks. We reviewed a theatre environmental risk assessment completed in May 2026, which detailed hazards, existing control measures and risk ratings using a risk matrix. This demonstrated a structured approach to identifying and managing environmental risks.

The centre also sought independent assurance regarding the safety of its theatre environments. An external specialist company carried out verification testing and checks within the theatres, including assessments of air supply, air change rates and room pressures. We reviewed the most recent inspection report from April 2026, which confirmed the theatres met the requirements of health technical memorandum (HTM) and achieved compliance with the required standards for ventilation performance.

The evidence showed a good standard. 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 had systems to ensure staffing levels were planned, monitored and reviewed to support the safe and effective delivery of care. A daily safety briefing and safety huddle were undertaken to review planned versus actual staffing levels across all departments. These meetings enabled staff to identify any staffing shortfalls, skill mix concerns or operational pressures that could impact patient care or planned activity. The potential impact on theatre lists and service delivery was considered, and actions were taken to maintain safe staffing levels. Any significant concerns were escalated to the senior management team (SMT) for review and support.

Staffing levels were monitored closely, and data provided for April and May 2026 demonstrated that planned staffing levels were consistently achieved, with no identified staffing gaps or workforce shortfalls. The centre did not use agency staff and instead relied on its own bank staff to cover sickness and annual leave. Data provided by the centre showed that bank staff usage was 21.6% in March 2026 and 18.3% in April 2026, supporting continuity of care by using staff who were familiar with the service and its processes.

Staff rotas were planned one month in advance to support workforce planning and help ensure sufficient numbers of appropriately skilled staff were available to meet patient needs.

Staff received training appropriate to their roles and responsibilities and were required to complete statutory and mandatory training through a combination of e-learning and face-to-face sessions. Training included subjects such as safeguarding and the Mental Capacity Act. Data provided by the centre showed overall mandatory training compliance was 92%. Each department had a designated lead who supported with oversight of staff training, competency and development.

The centre had processes to ensure staff were suitably skilled, competent and experienced to undertake their roles. Competency frameworks were used across the service, including Surgical First Assistant competencies, to provide assurance staff had the necessary skills to perform their duties safely and effectively. Employment reviews were undertaken to assess performance, professional development needs and, where applicable, practising privileges. Clinical review documentation included consideration of practising privileges to ensure clinicians remained competent and authorised to undertake their scope of practice. 

Staff also received annual appraisals to review achievements, discuss learning and development, and agree objectives for the coming year. However, appraisal completion rates for 2025 were 50%, which meant the service could not be assured that all staff had received a formal review of their performance and development needs within the required timeframe.

The centre monitored workforce metrics to support workforce sustainability and retention. Data provided showed the staff turnover rate was 8.93% in April 2026.

The organisation had policies to support professional standards and workforce capability. A Human Resources Capability for Medical and Dental Professionals Policy supported medical and dental practitioners to achieve and maintain appropriate professional standards and competencies. In addition, a Human Resources Capability Policy provided a framework to support employees in achieving and maintaining the standards expected by the organisation. These arrangements supported the development of a competent workforce capable of delivering safe and effective care.

The evidence showed a good standard. The centre assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The centre had systems and processes to prevent and control infection. Staff had access to an infection prevention and control (IPC) policy, which provided guidance on the prevention, identification and management of infection risks and supported staff to follow current best practice standards.

The environment was visibly clean and well maintained. Ward and theatre areas were clean, appropriately furnished and suitable for the delivery of care. Cleaning records were up to date and demonstrated that cleaning activities were completed routinely across the service. Equipment was clean and well maintained, and we observed in-date cleaning stickers on equipment, providing assurance that cleaning schedules were being followed.

Staff adhered to infection prevention and control principles. During the inspection, we observed staff following the ‘bare below the elbows’ guidance and maintaining good hand hygiene practices, including washing their hands between patient contacts.

Hand hygiene standards compliance was monitored through regular audits which showed 100% compliance in October 2025 and April 2026. This provided assurance that staff consistently followed hand hygiene requirements and good infection prevention practices.

The service also undertook regular environmental cleaning audits. The April 2026 cleaning audit recorded a compliance rate of 85.71%. The shortfall in compliance related to damage to a sink caused by a leaking roof. The issue had been identified by leaders, and an action plan was in place to address the environmental concerns and restore full compliance with cleaning standards.

Arrangements were in place for the decontamination of equipment and medical devices. The centre used their sister unit for decontamination services and had a decontamination policy to support safe practice. The policy outlined the cleaning and decontamination processes for equipment, medical devices and the healthcare environment, including guidance on approved cleaning products and the management of blood and body fluid spillages.

The service monitored surgical site infections to identify opportunities for improvement. Leaders reported one surgical site infection in the previous 12 months relating to ophthalmology. A post-infection review had been completed, and an action plan was implemented to identify learning and reduce the risk of recurrence.

IPC leadership and oversight were supported through designated IPC leads, who provided guidance, monitoring and assurance regarding IPC practices across the centre.

The evidence showed some shortfalls. The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

During the inspection, out-of-date medicines were identified and staff took prompt action to remove and replace them immediately, reducing the risk of expired medicines being available for use.

The service had systems and processes to support the safe and effective management of medicines. Staff had access to a medicines management policy which clearly outlined staff responsibilities, the competencies required to handle medicines safely and the processes necessary to ensure medicines were managed in accordance with legal requirements and best practice guidance. 

The service had a controlled drugs (CD) licence and maintained oversight of medicines management through a structured governance framework. Targeted medicines management and controlled drugs assurance spot checks were undertaken between formal quarterly audit cycles to provide assurance that previously identified areas of non-compliance had been addressed and remained compliant. Oversight was further supported through a medicines management committee, which met every six months to review audit findings, medication safety trends, learning from incidents, and compliance with relevant legislation and regulatory requirements. A spot-check action tracker was used to monitor progress and ensure identified improvements were implemented and sustained, supporting the safe and effective management of medicines across the service.

Supporting standard operating procedures (SOPs) were available for specific aspects of medicines management, including the labelling of patients' own medicines by the pharmacy department and the management of patients' own controlled drugs. These procedures provided staff with clear guidance to promote consistency and reduce the risk of medicines-related errors.

The centre monitored medicines management through a programme of audits. We reviewed medicines management audits completed in March and April 2026, which demonstrated 100% compliance. This provided assurance that medicines were being managed safely and in accordance with local policies and procedures.

Arrangements were in place for the management of controlled drugs. We checked controlled drug stock balances and records and they were accurate. Stock checks were undertaken twice daily and records demonstrated these checks were completed consistently, supporting effective oversight and accountability.

The centre also monitored compliance with VTE prophylaxis requirements. Pharmacological and mechanical prophylaxis were prescribed in line with NICE guidance and current evidence-based practice. 

Review of audit findings and incident-related learning had identified some variability in the documentation of mechanical prophylaxis application and removal, alongside occasional gaps in the timing and documentation of peri-operative pharmacological prophylaxis. Leaders had responded to these findings by implementing an improvement plan, including clarifying responsibilities for peri-operative anticoagulation timing and standardising documentation relating to mechanical prophylaxis in collaboration with the medical director. This demonstrated a commitment to continuous improvement and the optimisation of medicines-related practice.