Alderwood Medical Practice

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 contracts with the landlord of the building to ensure the premises was maintained. Staff told us the landlord did not always respond quickly to requests. For example, a radiator they had not been able to turn off for 2 months and broken locks on doors. Portable appliance testing (PAT) had been arranged for 23 July 2026. However, the provider was unable to demonstrate that calibration of equipment and the 5-year fixed wire testing (a routine check of a building's hidden electrical wires, sockets, and fuse boxes to make sure they are safe) were up to date. Staff told us weekly fire alarm testing was completed however, the provider was unable to provide records to confirm this. Systems to gain assurances from the landlord that required risk assessments such as legionella, fire, gas safety and fire drills had been completed, and any concerns acted on, were not in place. Up to date health and safety risk assessments had not been completed. For example, slips and trips and the safe storage of oxygen. Control of Substances Hazardous to Health (COSHH) risk assessments were in place for products used by domestic staff. However, COSHH risk assessments were not in place for products used by clinical and administrative staff. Following our assessment the provider completed the required COSHH risk assessments and sent them to us.

Some of the locks on consultation doors were broken or, doors were left unlocked by staff when not in use meaning they were unsecure. Systems for tracking prescription stationery throughout the practice were not effective. Following our assessment, the provider sent us an updated prescription tracking policy to address this and planned to carry out audits to monitor the effectiveness of the changes. On the day of our assessment, clinical waste such as full clinical waste bags and, cleaning products such as bleach and chlorine tablets, were stored in an unlocked cupboard in an unlocked room. At the end of our onsite assessment, the provider locked the room. Sharps boxes were left on the floor in the receptionist area however, the door was locked to prevent access.

Cupboards for storing patient paper records were not secure and notes awaiting summarisation were stored on the floor under a desk. Whilst the doors to these rooms were locked, a risk assessment to mitigate potential risks had not been completed. Systems to shield records from fire, water leaks, and direct sunlight were not in place.

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

The service mostly made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. A staff capacity assessment had been completed to determine the required clinical staffing levels required to meet the needs of people. Reasonable adjustments had been made for a member of staff and an additional member of staff recruited to address their reduction in hours.

However, staff told us that non-clinical staffing hours had been lost and not replaced meaning they were unable to complete all the required tasks, such as note summarisation and required training. We reviewed the staff rota for non-clinical staff and found there was no dedicated time for the summarisation of patient records, patient deductions or scanning and coding of hospital letters. We found notes for summarisation dated back to 2024 and 4,893 letters were waiting scanning and coding. The provider had audited the time people waited for the phone to be answered. The audit demonstrated that peak demand was on a Monday morning however, this information had not been used to inform staffing levels which remained the same on this day as all other days. Some staff had not received recent appraisals.

The service employed a range of clinical and non-clinical roles, which included GPs, nurses, and a pharmacist. Some staff were not up to date with required training, as identified by the provider. For example, infection prevention and control, sepsis, health and safety, manual handling and learning disability and autistic people support training. It was not clear how soon the provider expected new staff to have completed identified mandatory training. For example, a member of staff who had been working at the practice for 3 months had not completed any of the deemed mandatory training. Staff and leaders told us staff could complete training in their own time and received time back in lieu.

The service mostly followed safe recruitment procedures when employing staff, which were in line with national legislation. This included identity checks, review of qualifications, obtaining of professional references and a criminal records check. Where health or personal conditions were in place that may have impacted on a person’s ability to carry out their role, we saw that reasonable adjustments had been made and plans put in place to support them. A memorandum of understanding was in place for staff working in the practice, but employed by the Primary Care Network, to provide reassurance that staff were appropriately recruited, trained and supported.

Staff worked together well to provide safe care that met people’s individual needs. Auditing of the prescribing of non-medical prescribers had been completed however, the provider could not evidence that learning was shared with them through clinical supervision.
 

The service assessed the risk of infection however, the risk was not always monitored and controlled appropriately.

An infection prevention and control (IPC) plan had been put in place to address issues identified in the IPC audit. However, we found required actions by staff within the plan had not been adhered to and systems to monitor compliance were not in place. For example, we found some sharps bins were open and undated; there was no sharps bin in one of the clinical rooms; 4 packets of tea and crockery were found in a clinical room; and food in the staff fridge was not dated or named. There were several non-wipeable chairs in consultation rooms. There was a plan to replace them over time however, a system to mitigate potential risks until they were replaced was not in place.

A history of staff immunisations against potential healthcare acquired infections were not always up to date in line with national guidance. We reviewed the records of 4 members of staff and found there were no records for 2 of the members of staff and incomplete records for the other 2 members of staff.

The service had cleaning schedules available, which outlined how clinical and domestic staff should clean the building and its equipment. The service demonstrated how these were monitored for completion to maintain oversight of cleaning arrangements. Most staff had completed relevant training in IPC. During our onsite assessment, the service's premises and a sample of equipment reviewed was noted to be visibly clean and medical consumables were in date.
 

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