Westgate 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 remains the same.

This service scored 75 (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 detected and controlled potential risks in the care environment. They ensured equipment, facilities and technology supported the delivery of safe care.

Appropriate premises maintenance schedules were in place, recent maintenance documentation was reviewed, including the Electrical Installation Condition Report, gas safety certification, and records relating to fire alarms, fire extinguishers, and emergency lighting. Any actions highlighted had been completed within a reasonable time frame.

Risk assessments were in place, covering fire safety, Control of Substances Hazardous to Health, health and safety, and Legionella management.

Fire evacuation drills and routine fire alarm testing were undertaken, an accident book was available, and health and safety posters were displayed.

The service had a clear procedure for maintaining a safe environment for both patients and staff. This included daily discussions during the daily huddle, where any issues were logged to ensure required actions were completed.

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 team members, including GPs, nurses and health care assistants.

The service followed safe recruitment procedures when employing staff, which was in line with national legislation. This included identity checks, reviews of qualifications, the obtaining of professional references and criminal records check. Disclosure and Barring Service (DBS) checks were completed prior to all staff commencing employment and were renewed on a 3-yearly basis. Process were in place to undertake appraisals.

Clinical supervision was well established, with sessions clearly recorded, documented, and scheduled. Learning was actively promoted through case studies, presentations and discussions, supported by accessible documentation and supervision display boards. Staff were able to review supervision materials, reinforcing continuous learning. Audit processes were effective, with targeted supervision leading to measurable improvements in clinician performance following re-assessment.

The service maintained a comprehensive locum pack that was updated regularly and given to locum staff at each visit. Leaders requested agencies provide evidence of locums’ registrations, qualifications, DBS checks and right to work documents.

Leaders ensured staff were up to date with all mandatory training, and they maintained an overview of all completed training. There were processes in place to remind staff of upcoming training, and staff were given protected time to complete it.

The practice was an established training practice with a strong record of supporting the development of future healthcare professionals.

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 dedicated infection prevention and control (IPC) lead, who had received training for this role. The IPC lead regularly attended forums to keep knowledge up to date. An IPC audit was completed in March 2026, this audit showed good standards of infection control. We reviewed a sample of consultation rooms, all were clean, tidy and clutter free. Stock held in these rooms was in date. Hand hygiene audits were conducted and showed good knowledge of the correct hand-washing procedure.

A contract for cleaning was in place, with colour coded mops and cloths stored in a dedicated area. The service provided evidence of cleaning audits, conducted by the cleaning service.

Staff immunisation status was recorded and stored in staff files.

Handwashing posters and sharps injury posters were clearly displayed throughout the service. Sharps bins in clinical rooms were appropriately labelled, and safety procedures were followed when the room was not in use. Full sharps bins were properly sealed, however, the room they were stored in was not locked, and was accessible to patients. We discussed this with the service, and they advised us they were planning to purchase external storage that could be kept locked.

Staff completed annual IPC training, relevant to their role.

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