The Fullwell Avenue 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.

Staff effectively identified and managed risks within the care environment, ensuring equipment, facilities, and technology supported delivery of safe care. There were maintenance contracts to uphold safety standards.

Staff and leaders undertook health and safety audits and risk assessments, including electrical, gas, and Legionella, which had been completed within the past 12 months, with all identified risks addressed. The practice provided evidence of annual portable appliance testing, and calibration of equipment. The service had a business continuity plan which was regularly reviewed to manage major service disruptions. Staff reported no concerns regarding health and safety arrangements.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. Leaders followed safe recruitment processes when employing staff in line with national legislation. This included identity checks, review of qualifications, obtaining professional references and a criminal records check. We saw the induction checklist was used during induction of new staff.

Staff vaccinations were not always kept up to date in line with Green Book guidance. Although 5 staff members whose files we checked had completed hepatitis B screening and vaccination, there was no record of other routine immunisations. There was no record of MMR vaccination for 4 of these staff, one of whom was a clinical member of staff. Where vaccination history was not available, there was no record of risk assessments undertaken or evidence of referral to the Occupational Health Service. Managers responded promptly to our findings and told us they would arrange risk assessments and review recruitment procedures to ensure ongoing compliance in these areas.

Leaders used an electronic management tool to monitor completion of mandatory staff training. We reviewed records which some showed gaps in completion. The gaps in completed training were immediately reviewed and rectified by the practice. Learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence. Staff participated in monthly protected learning time (PLT) sessions focused on learning and professional development. Most staff had received an annual appraisal. Where people had specialist needs, staff had received training on how to support autistic people and people with a learning disability.

At the time of this assessment, managers had not provided reception staff with Care Navigator training to undertake their role. However, we saw reception staff followed a care navigation flowchart which helped to provide consistency of experience for patients contacting the service. Clinical staff and non-medical prescribers received support and supervision meetings were routinely documented.

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. We observed that the facilities and premises were visibly clean, and systems were in place to prevent the spread of infection. Personal protective equipment (PPE) was well stocked and placed appropriately throughout the building. There was a dedicated lead for infection prevention and control. Staff had received training relevant to their roles.

Cleaning schedules were in place, and regular infection control and cleaning audits were conducted to maintain standards. Clinical waste, sharps, and clinical specimens were managed carefully to keep everyone safe.

However, staff vaccinations were not always kept up to date in line with the latest UK Health Security Agency (UKHSA) guidance. There was a clear system for reporting infection concerns to the relevant agencies, such as notifiable diseases.

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