South Saxon House 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 staff protected people from avoidable harm and made sure care was delivered from environments that were clean and well maintained. At our last assessment, we rated this key question as good. At this assessment, the rating remains the same.

This service scored 66 (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 always make sure equipment, facilities and technology supported the delivery of safe care.

The service had not systematically ensured all risks in relation to health and safety were formally documented. The absence of specific risk assessments reduced the service’s ability to demonstrate that risks had been appropriately assessed, suitable controls identified and the potential impact of those risks understood. Additionally, the service did not have effective arrangements in place to monitor and ensure ongoing compliance.

The service had not identified the potential risk of water stagnation from an infrequently used outlet on the first floor. This risk had not been identified during the Legionella bacteria risk assessment completed in October 2025.

Specific risk assessments regarding security were not in place. However, we saw staff meeting minutes from April 2026 which demonstrated discussions regarding premises risks such as premises security, fridge security and prescription security.

The service had contracts in place to ensure the premises were well maintained. For example, gas and electrical equipment had annual servicing and medical equipment was calibrated in line with manufacturers’ recommendations. We saw evidence to confirm portable appliances were tested on an annual basis.

However, a fire safety risk assessment had been completed, and a Fire drill had been conducted in November 2025. This took place outside service hours to minimise service disruption whilst enabling staff to practise emergency evacuation. Records showed that the evacuation process was effective. Learning was identified following the drill as not all staff had signed into the duty book. Learning was shared with staff and the importance of signing in was reinforced.

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

Hallways and corridors were noted to be tidy and free from clutter. Staff offices were secure, and access was restricted from the public. All people we spoke to as part of our assessment shared that they felt safe and comfortable in the service environment.

Following our assessment the service updated the legionella risk assessment and implemented weekly tap flushing of the outlet on the first floor to mitigate the risk. Additionally, the service introduced a risk register to proactively identify, monitor and mitigate all risks.

The service had not ensured all staff had completed training that it deemed as mandatory. Safe recruitment processes were not in line with regulatory requirements.
The service did not always ensure all pre-employment checks were completed in line with national requirements prior to staff commencing work. We reviewed 3 staff records. For one staff member there were unexplained gaps in their employment history and there was no immunisation history recorded. There were also gaps in immunisation history for another staff member.
Leaders had not assured that staff were up to date with training. Several staff were overdue training at the time of our assessment. This included training the service had identified as mandatory such as hand hygiene, moving and handling, mental capacity awareness, Learning Disabilities and Autism, and health and safety.
Clinical supervision took place between leaders and individual staff. Discussions were recorded in peoples’ individual clinical records however evidence was not available to demonstrate clinical learning and development for the individual staff members. The service had not used the supervision record template available in their clinical supervision policy.
However, they made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They employed a small team across a range of clinical and non-clinical roles. Additionally, a physiotherapist, employed by the Primary Care Network (PCN) provided regular clinics. The service was also supported by regular locum staff to include a locum GP and an advanced nurse practitioner. They worked together well to provide safe care that met people’s individual needs.
Following our assessment, the service shared evidence staff immunisation records had been updated. The service also reviewed the gaps in employment history and discussed them with the relevant staff member. The service revised its’ training matrix and told us staff were working to update their training compliance. The service told us that use of a clinical supervision record template had been implemented to support staff learning and development and to agree ongoing actions. An example of this was shared with us.

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.
The service did not have sufficient assurance in place in relation to infection, prevention and control (IPC). This included gaps in staff training, environmental management, waste security and documentary assurance of cleaning processes. Opportunities for improvement were identified.
COSHH (Control of Substances Hazardous to Health) product data sheets were not available.
There were no formal cleaning schedules for cleaning of clinical equipment. The clinical staff told us they cleaned equipment each time they used it but there were no records to support this.
Storage of bulk waste required improvement. Although all 4 clinical bulk waste bins held on site at the time of our assessment were locked, 2 bins were not adequately secured to prevent access by the public.
Cleaning of the building and its equipment were managed by a hybrid arrangement. An independent cleaner attended 4 days per week with environment cleaning schedules in place demonstrating completion. On the 5th day, when only part of the premises was utilised, staff took responsibility to clean the used areas and complete checks in line with IPC. However, there were no records to demonstrate this.
The service had a designated IPC lead who had completed all relevant training for IPC. An IPC audit had been conducted to ensure compliance. Staff meeting minutes highlighted the importance and the process of hand hygiene and hand hygiene audits had been completed with no actions identified. However, hand hygiene training for one clinician had not been completed.
However, during our onsite visit, the service's premises and a sample of equipment reviewed was noted to be visibly clean. People we spoke to during our assessment informed that they were satisfied with the cleanliness and hygiene of the service and staff.
Sharps bins were found to be appropriately managed and not overfilled
Staff were asked about specimen handling protocols, and they were able to explain the safe management processes in line with current guidelines.
Following our assessment, staff acted to address the absence of COSHH product data sheets and told us that all relevant COSHH for the products used on site, are now stored alongside the products. Additionally, the service implemented a cleaning log for all cleaning completed by the service staff. Evidence was also shared to demonstrate staff training compliance for hand hygiene.
The service told us the unsecured bulk waste bins were collected from site the day following our assessment.
 

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