John G. Plummer & Associates Thorpe St. Andrew

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 found this practice was providing safe care in line with the relevant regulations and had taken into consideration appropriate guidance.

Although there are issues to be addressed, the impact of our concerns relates to the governance and oversight of the risks, rather than a patient safety risk.

Find out what we look at when we assess this area in our information about our new Single assessment framework.

The judgement for Learning culture is based on the latest evidence we assessed for the Safe key question.

The judgement for Safe systems, pathways and transitions is based on the latest evidence we assessed for the Safe key question.

The judgement for Safeguarding is based on the latest evidence we assessed for the Safe key question.

The judgement for Involving people to manage risks is based on the latest evidence we assessed for the Safe key question.

The practice identified and managed most risks effectively and staff described the processes. This included sharps safety, sepsis awareness and lone working.

A fire risk assessment had been completed in March 2024. However, multiple high-risk actions were still outstanding. Additionally, the emergency lighting was not being routinely tested. Following this feedback, the practice told us that the outstanding actions in the risk assessment will be completed within a reasonable timeframe, and that testing of the emergency lighting will commence after training.

The practice had not ensured that the facilities were maintained in accordance with regulations, as there had not been an Electrical Installation Condition Report (EICR) to ensure the electrical system and wiring in the building was safe. Following this feedback, we saw that an electrician had been scheduled to carry this out.

Staff could access emergency equipment and medicines that were checked in line with national guidance. They knew how to respond to a medical emergency and had completed training in emergency resuscitation and basic life support every year.

Staff providing treatment to patients under sedation had also completed immediate life support training.

The premises were visibly clean, well maintained and free from clutter. Hazardous substances were clearly labelled and stored safely.

We saw satisfactory records of servicing and validation of equipment in line with manufacturer’s instructions.

The practice had arrangements to ensure the safety of the X-ray equipment, and the required radiation protection information was available.

The practice had systems for appropriate and safe management of medicines. NHS prescription pads were kept securely, and a log was in place to monitor and track their use.

The practice had a recruitment policy that reflected relevant legislation, to help them employ suitable staff, including agency or locum staff. However, we saw that the policy was not consistently followed, as there were incomplete records for multiple staff members, including a lack of evidence of immunity to Hepatitis B and lack of proof of conduct in previous employment. Improvements were required to ensure that accurate, complete and detailed records were maintained for all staff. Following this feedback, the practice told us that the partners will discuss and implement changes as soon as possible.

Newly appointed staff had an appropriate role specific structured induction; however, this was not always documented. Following this feedback, the practice told us this process will be improved.

Staff had the skills, knowledge and experience to carry out their roles. They told us that there were enough staff on duty at all times. They demonstrated knowledge of safeguarding and were aware of how safeguarding information could be accessed. We saw that the training for some staff was completed on the day of and day following the inspection. Improvements should be made to ensure that safeguarding training was updated on an ongoing basis. Staff knew how to escalate safeguarding concerns within the practice and externally.

The practice did not have comprehensive arrangements in place to ensure staff training, including continuing professional development, was up-to-date and reviewed at the required intervals. For example, we saw that not all staff had completed Infection Prevention and Control (IPC) training or fire safety training. Following this feedback, the practice told us that this will be reviewed, and a new process implemented to ensure all training is completed.

There were effective processes to support and develop staff with additional roles and responsibilities. Staff discussed their learning needs, general wellbeing and aims for future professional development during annual appraisals, practice team meetings and ongoing informal discussions.

Staff felt respected, supported and valued, and they were proud to work in the practice.

The practice had infection control procedures that reflected published guidance.

Staff received appropriate training and demonstrated knowledge and awareness of infection prevention and control processes.

Staff used personal protective equipment and decontaminated dental instruments after use, in line with national guidance. We saw, and staff confirmed that single-use items were not reprocessed.

The practice had effective procedures to reduce the risk of Legionella, or other bacteria, developing in water systems, in line with a risk assessment and current guidance.

The practice had protocols to ensure effective cleaning; however, improvements could be made to implement cleaning schedules. We saw that there was safe segregation and disposal of hazardous waste.

Equipment was maintained and serviced in line with manufacturers’ instructions.

The practice completed infection prevention and control audits in line with current guidance.

The judgement for Medicines optimisation is based on the latest evidence we assessed for the Safe key question.