Fernclough 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 has changed to requires improvement.

The service was in breach of legal regulation in relation premises and equipment.

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.

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. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

The service did not ensure that the premises and equipment were safe, suitable, or well maintained. Appropriate risk assessments were not in place relevant to the building, including fire safety, legionella, COSHH, or reasonable adjustments. The provider had not undertaken legionella monitoring, did not have a written fire evacuation plan, and had not carried out fire drills or checks of emergency lighting. We identified environmental hazards, including a portable heater in use, the absence of a carbon monoxide detector, and rear fire door that was not compliant with fire safety regulations. The service had not completed a privacy impact assessment for the use for CCTV. We found out of date consumables in the surgery room including syringes. There was a damp patch and mould observed on a wall in the reception area, which had previously been reported to the leadership team, but no action had been taken to have the issue fixed.

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. However, we found that staff were not always up to date with their training which the service had deemed mandatory and operated within their agreed areas of competence, for example all staff did not have up to date basic life support training. Recruitment folders did not always have the required checks documented such as checking of right to work.

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 cleaning schedules available, which outlined how staff should clean the building and its equipment. The service demonstrated how these were monitored for completion to maintain oversight of cleaning arrangements. 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.