Pembroke 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 people were protected from abuse and avoidable harm.

At our last inspection in March 2016, we rated this key question as Good. At this inspection, the rating remains the same and continues to be rated Good.

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 at both the main practice and the branch practice. We visited both practices, and observed they were both well maintained and there were systems to ensure equipment was safe to use. We saw risk assessments were in place for fire safety and legionella, and actions had been taken. Staff made sure equipment, facilities and technology supported the delivery of safe care. For example, regular testing, auditing and calibration of equipment. There was a business continuity plan in place which was monitored and reviewed.

The service used a designated tool called the ‘Primary Care Workforce Calculator’ to ensure there were enough qualified, skilled and experienced staff. There were a range of clinical and non-clinical roles within the practice.

Staff told us that leaders and GPs were available throughout the day if they needed advice. Patient feedback also highlighted how responsive the practice was in terms of access to staff.

We looked at 5 staff files and found recruitment checks had been carried out in accordance with regulations. However, in 1 file we found the recording of checks could be improved, to include a documented explanation of missing staff vaccination records. On feeding this back, the practice responded positively, and conducted a risk assessment to address the concern until proof of vaccination was provided.

Staff feedback and evidence suggested that staff received effective support, supervision and development.

Staff also told us how they worked together and with staff from other practices within the primary care network (PCN) to coordinate training and to provide safe care that met communities’ needs.

This inspection included a site visit to both the main practice and the branch practice, we saw the provider assessed and managed the risk of infection. The practice had a designated infection, prevention and control (IPC) lead and staff had had relevant training. The practice had sought additional specialist advice regarding IPC from the Integrated Care Board and shared monthly IPC updates with staff. Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks. There was a live risk register which managed and mitigated associated risks which also included various timetables of when the checks and risk assessments required repeating.

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