Dr John Segarajasinghe Also known as The Pine Street 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 patients 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, and 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.

The practice had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Patients felt supported to raise concerns and felt staff treated them with compassion and understanding. Leaders encouraged staff to raise concerns when things went wrong. Staff felt there was an open culture, and that safety was a top priority. The practice had processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave patient support. Learning from incidents and complaints resulted in changes that improved care for others.

The practice had an effective process for recording and acting on safety alerts received into the practice, such as those from the Medicines and Healthcare Products Regulatory Agency (MHRA). Clinical guidance from these safety alerts was discussed at clinical meetings, shared with staff and embedded into routine practice. For example, a recent MHRA safety alert regarding finasteride and dutasteride (used to treat benign enlargement of the prostate) was reviewed by the practice. The alert highlighted risks of depression, suicidal thoughts and behaviours, and sexual dysfunction that may persist after treatment had stopped. The alert was shared during clinical meetings, and emails were circulated to all clinicians to support safe prescribing and medication reviews.

The practice worked with patient and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when a patient moved between different services.

There were systems in place for processing information relating to new patients. The practice worked with other practices to deliver shared care and when patients moved between services.

There were protocols for managing correspondence and test results. Requesting clinicians were responsible for processing their own results. The workload was shared with other clinicians in their absence. Our review from clinical searches confirmed that correspondence and laboratory results were processed in a timely way.

The practice worked with patients and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving patient’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

There were dedicated GP leads for safeguarding adults and children. All the staff we spoke with or received feedback from knew who the leads were and what steps to take if they had any concerns.They gave clear examples of what constitutes safeguarding and demonstrated confidence in recognising concerns and taking appropriate action.All staff had completed their safeguarding adults and children training to the level appropriate for their roles.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. The practice maintained a list of vulnerable patients and acted on concerns working in partnership with other organisations. Alerts were visible on the clinical system to ensure staff could manage patients appropriately and safeguarding discussions took place during clinical meetings.

The practice worked with patients to understand and manage risks by thinking holistically. They provided care to meet patient’s needs that was safe, supportive and enabled patient to do the things that mattered to them.

Staff could recognise a deteriorating patient and knew of action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

During the assessment we reviewed staff training records that confirmed all staff had completed training in child and adult basic life support and anaphylaxis. The practice also required staff to complete training in sepsis awareness every year. Four staff records were reviewed, and evidence showed that sepsis awareness training had been completed by all staff members.

The practice held appropriate emergency medicines, and a system had been implemented to monitor the expiry dates of emergency medicines. Benzylpenicillin, (an antibiotic used to treat serious bacterial infections such as suspected meningococcal disease) was not available within the practice which increased risk to people who may require urgent treatment for bacterial meningitis or meningococcal disease. In addition, Diclofenac (an anti-inflammatory medicine used to treat pain and inflammation) was not available at the time of the inspection. The practice provided evidence that these medicines had been ordered weeks before the inspection and were awaiting supply due to shortage of pharmacy stock. The practice confirmed that an arrangement was in place with a neighbouring practice located within the same building to obtain these medicines if required until stock became available. However appropriate risk assessments were not evidenced to demonstrate a consistent process to manage emergency medicine risks.

The practice detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The practice was located in premises owned by NHS Property Services. The practice was located within a Grade 1 listed building, which placed significant constraints on alterations and required appropriate approval through the Listed Building Consent process from English Heritage. As a result, proposed changes were often complex and could take considerable time to be planned, approved and implemented.

Responsibility for fire and Legionella risk assessments rested with NHS Property Services; however, oversight of the completion of assessments and associated action plans was maintained by the practice. Contracts were in place through NHS Property Services to ensure the premises were cleaned and maintained appropriately, and responsibility for the management of substances hazardous to health (COSHH) was held by NHS Property Services. Evidence demonstrated that the practice monitored identified risks and liaised with NHS Property Services to progress required actions where necessary.

Health and safety risk assessments and audits had been undertaken and risks identified had been addressed.

The practice had also carried out internal Infection Prevention and Control (IPC) audits and fire risk assessments to monitor risks within its environment. Evidence was seen of the practice actively liaised with NHS Property Services to progress required works and address identified environmental risks, helping to ensure the premises remained as safe and suitable as possible for people using the service and staff.

Emergency equipment was maintained appropriately; however, concerns were identified regarding the accessibility of the only automated external defibrillator (AED) on site stored in the clinical room on the ground floor, as most patients were seen on the first floor and one consulting room was available on the ground floor for patients with mobility needs. Following inspection feedback, leaders responded immediately by purchasing an additional AED on the same day, and evidence of this action was provided to us.

There was a business continuity plan in place which was monitored and reviewed.

The practice 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 patient’s individual needs.

There were a range of clinical and non-clinical roles within the practice. We found training was up to date, learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence. Staff had protected time for learning and development. There were enough staff to provide appointments, support continuity of care and prevent staff from working excessive hours.

Overall, the practice had implemented safe recruitment processes. A review of 4 staff recruitment files found that disclosure and barring checks (DBS), professional registration and identity checks had been completed for staff, and records showed that other required vaccinations were up to date. The service had a tracker to ensure staff appraisals were completed in a timely way and that professional registrations were kept up to date. Staff had access to regular appraisal, one to one, mentoring, and clinical supervision. Records showed that all staff had received an appraisal within the recommended timeframe in line with the practice’s staff policy. However, recruitment records were not always complete. Evidence of qualifications was not available in the files reviewed, and evidence of the recommended Diphtheria, Tetanus, and acellular Pertussis (DTaP) vaccination was not available for 2 staff members. References were not present in 3 of the 4 staff recruitment files reviewed. The practice told us that recruitment decisions had previously been supported through DBS checks, management oversight and probationary processes, and that references had not routinely been obtained for staff recruited. The practice updated its recruitment policy in June 2026. We were informed that the revised policy had introduced a requirement for references to be obtained as part of the recruitment process, and the staff files without references related to individuals employed prior to this change.

The practice assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The practice had a designated infection, prevention and control lead and all staff had had relevant training. Risk assessments and audits were completed, and actions taken to mitigate risks. Health promotion posters were displayed throughout the practice. Policies and guidance were available to staff, including as part of the induction process, and were tailored to their roles.

The premises were managed by NHS Property Services, which had arrangements in place with external contractors to provide cleaning services, while oversight of cleaning effectiveness was maintained by the practice. COSHH cabinets and cleaning equipment were maintained by NHS Property Services and were not the responsibility of the practice.

During our site visit we looked at a selection of staff records and found that staff had received all the recommended vaccinations except for the Diphtheria, Tetanus, and acellular Pertussis (DTaP) vaccination. The practice told us they were not aware that this vaccination was required for relevant staff, as their contracted occupational health provider had not advised them of this requirement. Following our feedback, staff had been offered and received the required vaccinations.

The practice was located within a Grade I listed building, and any internal or external alterations were required to be approved through the appropriate heritage approval processes. IPC risks had been identified through the practice's infection prevention and control audits, including the absence of elbow operated taps in some clinical rooms and deterioration to wall surfaces. Evidence of correspondence demonstrated that these issues had been raised with NHS Property Services who liaised with English heritage, and requests for the necessary remedial works had been made.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

Staff received regular medicines management training and competency assessments and were confident in the safe storage, administration, and recording of medicines. Medicines, including vaccines requiring refrigeration, were stored securely and monitored appropriately, with fridge temperatures checked daily. Staff understood the actions required if temperatures fell outside safe limits.

Staff carried out regular checks of stock levels and medicine expiry dates. Medical gases, including oxygen, were stored safely, and prescription stationery was kept securely and managed appropriately.

Patient Group Directive (PGDs) and Patient Specific Directive (PSDs) were appropriately managed and maintained to support the safe supply and administration of medicines. A PGD provides a legal framework for the supply and administration of specified medicines to defined groups of patients, were appropriately documented and signed.

There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.

As part of our assessment a number of set clinical record searches were undertaken by a CQC GP specialist advisor. These searches were completed with the consent of the provider, to review if the practice was assessing and delivering care and treatment in line with current legislation, standards and evidence-based guidance.

Our review of records showed regular medicines reviews were carried out for the majority of people who used the service to ensure their medicines were safe and appropriate for their needs. However, we did identified that for a small number of patients either a medicine review or blood monitoring was overdue or 1 patient who required further clinical review and appropriate coding on the clinical system

The practice had systems to manage and respond to safety alerts and medicine recalls. There was evidence that safety alerts had been actioned, and patient received the correct information about any risks associated with their medicines.

Medication reviews were appropriately documented and recorded on the clinical system.

Prescribing data relating to hypnotics and antibiotics had not been routinely monitored, and staff were not aware that prescribing levels were higher than expected. The practice stated that this would be reviewed to identify any learning and improvement opportunities.