Napier Road 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.

This is the first inspection for this service since its registration with CQC. This key question has been rated as Good.

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.

The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety, investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Leaders encouraged staff to raise concerns when things went wrong. Incidents were discussed during meetings to ensure that learning was shared. Staff felt there was an open culture, and that safety was a top priority. The service 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, staff identified an issue involving the urgent referral process from the patient hub of the service’s Primary Care Network (PCN) which covered services outside of normal operating hours. It was identified that urgent referrals from the patient hub were not being identified in a timely manner by the reception team due to patient hub GPs not marking the referral clearly as urgent. An incident occurred where an urgent referral wasn’t identified and actioned for 6 days. Learning from the incident included that any urgent referral from the patient hub needed to be clearly marked as urgent in the correspondence so that it could be identified and actioned promptly.

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 for processing information relating to people who were newly registered. The service had nominated staff who processed the administration of new registrations.

The service worked with other providers to deliver shared care when people moved between services.

The service worked with a local community service to ensure people received blood tests. The service did not conduct blood tests at their premises but referred people to a local community service where they conducted the pathology tests. Results were shared with the service and reviewed by the PCN pharmacy team who took action as required.

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.

The service had a safeguarding lead who was responsible for the coordination and monitoring of safeguarding for the service.

Staff were aware of safeguarding policies, procedures and they were appropriately trained in safeguarding for their role. The service maintained a list of vulnerable people and acted on concerns working in partnership with other organisations. For example, the service raised and followed-up safeguarding cases with the local authority so they were aware of relevant outcomes and actions, and could update their records and the team. The service held safeguarding meetings every 3 months where the safeguarding register was reviewed.

Staff would approach the safeguarding lead if they were concerned about a person. For example, staff told us they approached the safeguarding lead if their monitoring process for did not attend (DNA) appointments picked up safeguarding concerns associated with non-attendance.

The service did not have meetings with external bodies. However, the service used external safeguarding resources when suitable. For example, the service used a recent Multi-Agency Safeguarding Hub (MASH) report on approaches to maternity support for vulnerable adults to support a person using the service.

The service did not always work well with people to understand and manage risks. They did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We found that staff had difficulty locating emergency equipment and emergency medicines during our onsite visit.

Emergency medicines and equipment were not always readily accessible. Some medicines were stored in a locked treatment room and others in a locked vaccine fridge. This required staff to locate separate keys to gain access. This arrangement could delay access to emergency medicines and did not support prompt availability in an emergency. Staff were not always able to demonstrate an understanding of where emergency medicines and equipment were in the service when questioned. Managers could not demonstrate that risks associated with the storage of emergency medicines and equipment had been formally assessed, as no risk assessments had been conducted. Following the assessment, the service sent us evidence that they had introduced grab bags of emergency medicines which were in a more accessible location. Additionally, they had completed simulations to reinforce where equipment was held alongside emergency procedures for the service.

Emergency equipment continued to be stored in different locations across the practice, but managers gave clear reasons for why they had chosen to do this. For example, the Automated External Defibrillator (AED) was stored behind reception to ensure quick access for staff if they saw an emergency in the waiting room. Staff were reminded of these locations as part of their simulation training.

However, staff could recognise a deteriorating person and demonstrated knowledge of the service’s emergency processes. Staff had completed basic life support training. The lead GP and reception team signposted people to suitable services if their health needs were urgent. Reception staff had completed training in signposting and sepsis recognition.

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 ensured the premises were maintained. Health and safety risk assessments and audits had been completed and risks identified had been addressed. For example, the service identified on the health and safety risk assessment in January 2026 that there was minor damage to the building guttering and needed replacing. This was addressed and completed in February 2026.

Managers reviewed a fire risk assessment annually to ensure compliance with fire regulations. The fire risk assessment was last reviewed in June 2025, and fire alarms and extinguishers were serviced in July and August 2025 respectively. Gas safety was assessed and had been completed in March 2026.

The service had assessed the risk of Legionella and any risk identified had been addressed. For example, the service conducted routine water testing and monitored water temperatures.

There was a business continuity plan 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.

The service employed a small team. There were a range of clinical and non-clinical roles in the service with some individuals working for the Primary Care Network (PCN) the service was partnered with. The service worked with the PCN to ensure appropriate clinical cover was provided when the lead GP was away from work, for example, for annual leave.

Staff had undergone Disclosure and Barring Service checks (DBS is a way for employers to assess the suitability of individuals for certain roles) or if a DBS had not been completed, appropriate risk assessments had been conducted.

Staff received a full induction with reviews at 3 and 6 months as part of a structured probation period. Staff were working in their agreed areas of competence. Safe recruitment practices were followed.

Learning needs and development of staff was managed appropriately through annual appraisals.

However, despite staff being up to date with their training. We did not see evidence that managers had processes that provided oversight for completion rates and renewal timeframes.

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 (IPC) lead and all staff had relevant training for their role. Cleaning schedules were followed and completed accurately.

Risk assessments and audits were completed, and actions taken to mitigate risks. The service conducted an IPC risk assessment in November 2025, and compliance audits were completed on a quarterly basis with the most recent one completed in April 2026. Risks identified had been addressed. For example, in April it was identified that wallpaper was damaged and not in a fit state of repair. The service had taken action and improvements implemented in May 2026.

Clinical waste arrangements were suitable. Sharps bins were not overfilled, and clinical waste bins were locked and secure. Staff managed clinical specimen samples in a safe manner with awareness of IPC principles.

However, the storage arrangements for cleaning equipment did not always meet national guidance as the proximity of mop heads touched one another in storage areas. This meant that there was a risk of cross contamination. We raised this with the service who acknowledged our concerns. Following our onsite visit, the service confirmed concerns identified had been mitigated through a review of the storage arrangements.

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.

We conducted remote clinical searches on 22 May 2026 and found 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 unexpected symptoms. People told us they felt confident about their GP’s care and that questions they had would be answered. For example, our clinical searches identified 5 people diagnosed with asthma who had experienced an exacerbation of their condition. We reviewed these records and found people received appropriate clinical interventions and follow up.

The service had effective systems to manage and respond to safety alerts and medicine recalls. Pharmacy staff forwarded all alerts for distribution to all staff and searched for people impacted by the safety alerts. Potential changes in medication were reviewed where needed. For example,

We reviewed 2 records that found monitoring processes for high blood pressure and heart conditions were suitable.

Staff followed protocols to ensure they prescribed medicines safely and ensured medicine reviews contained necessary information to support continued prescribing and appropriate outcomes. We reviewed 5 records for people who had received a medicine review in the past 3 months and noted the reviews contained necessary information in line with best practice guidance.

Staff felt confident managing the storage, administration and recording of medicines. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines.

Staff managed prescription stationery appropriately and securely.

Waste medicines were recorded and disposed of appropriately including medicines returned by people who use the service. 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. For example, prescribing data reviewed as part of our assessment for the number of hypnotics and antibiotics prescribed by the service was lower than local and national averages.

Staff conducted a programme of regular clinical audits of prescribing that focused on improving care and treatment.