Ashfield Road 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 69 (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 make sure equipment, facilities and technology supported the delivery of safe care.

The service had contracts to ensure the premises and equipment were maintained. The premises were clean, tidy and free from clutter. There were security measures in place to protect personal safety of staff and people using the service as well as equipment and the premises.

Equipment was routinely checked and calibrated to ensure they were safe to use. Staff were aware of actions to take if equipment was faulty. Safety alerts and new guidance for equipment was shared in various ways such as by email and discussions at meetings.

Risk assessments relating to fire safety, COSHH (Control of Substances Hazardous to Health), and individual staff requirements were available. However, other health and safety risk assessment documents were not available at the time of the inspection, for example DSE (Display Screen Equipment), slips and trips and personal safety.

We saw evidence from meetings where risks had been discussed, and actions agreed to mitigate identified concerns however these were not risk assessed and documented appropriately. Following the on-site visit, the service provided additional risk assessment documentation and demonstrated the implementation of a clear new system to ensure that all risk assessments, identified risks, and resulting actions were recorded, monitored, and maintained effectively.

At the time of the onsite assessment, there was no documented evidence to show that a fire drill had been completed within the previous 18 months. Fire drills are important in providing assurance that emergency procedures are effective, identifying areas for improvement, and helping staff remain confident in evacuation procedures. Following the assessment, the provider implemented a new fire drill recording template and provided evidence that a fire drill had been completed. The provider also demonstrated that a schedule had been established to ensure fire drills are conducted, recorded and monitored at regular intervals.

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. We were provided with examples of when the business continuity plan had been used and the plan, actions and effectiveness had been reviewed and improved following the event. Staff were aware of how to access the business continuity plan and aware of various action plans included.

The service did not consistently ensure that recruitment processes were effective or that staff were up to date with all required training. However, staff received regular supervision and support, and worked effectively to deliver safe, person-centred care that met people's individual needs.

The service employed a range of clinical and non-clinical staff who worked within their scope of competence. We reviewed a sample of training records and found that some training had not been completed within the required timeframe. Training requirements were based on staff roles; however, we identified some instances where training had not been allocated correctly. Of the training records reviewed, 81% showed the required training had been correctly allocated and completed. The provider addressed the allocation issues during the onsite assessment and subsequently provided evidence that all outstanding training had been completed.

The service followed a recruitment process that included identity checks, verification of qualifications and obtaining references. There had been a recent change to the process for obtaining Disclosure and Barring Service (DBS) checks. As a result, DBS checks had not been completed for the most recently recruited staff. At the time of the assessment, there were no documented risk assessments or records to support and justify the revised process. Following the on-site assessment we received evidence that the process had been risk assessed and actioned in line, with guidance, and all outstanding DBS checks had been applied for.

Staff were knowledgeable, confident and had a clear understanding of their roles and responsibilities. They spoke positively about their work and were able to demonstrate how they carried out their duties effectively.

We saw evidence of regular supervision and appraisals and were provided with examples of the day-to-day support available to staff. Staff told us that leaders were open and approachable, and that they provided support and guidance to help staff carry out their roles effectively and maintain service delivery.

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 cleaning schedules in place which outlined how staff should clean the premises and equipment. During the onsite assessment, the premises and a sample of equipment reviewed were visibly clean. The infection prevention and control lead carried out regular audits to monitor compliance and took action where required to address any identified risks. Staff had completed infection prevention and control training appropriate to their roles. Staff immunisation records were maintained, and personal protective equipment (PPE) was available in key areas throughout the premises. People who used the service told us they felt safe and believed appropriate measures were in place to reduce the risk of infection spread.

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