Dr Amrish Gor Also known as Havergal 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, we focused on 3 quality statements relating to the key question Safe: Safe environments, Safe and effective staffing and Infection prevention and control (IPC).

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.

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

The practice had arrangements in place to ensure the premises were maintained. Staff and leaders completed health and safety risk assessments and undertook audits to ensure they had identified and addressed all risks.

Potential risks in the care environment were well-managed. The premises were converted from 2 adjoining domestic properties. A permanent access ramp had been installed to assist people with mobility issues, and a ground floor consulting room was reserved for their use. There were 6 other consultation rooms accessible by stairs.

A general risk assessment of the premises was conducted in March 2026. A Fire Safety risk assessment had been carried out in June 2026. Emergency lighting and fire extinguishers had been inspected and certified. We saw records confirming regular fire alarm testing was carried out and fire drills conducted. Portable appliance safety testing (PAT) and the fixed wiring inspection and certification had been completed in March 2026. The gas boiler and pipework were inspected and certified in May 2026.

The practice had up to date policies covering health, safety and welfare. We saw evidence staff had completed mandatory safety training.

The practice had appropriate equipment and medicines for use in medical emergencies. These included an oxygen supply, with suitable fittings for children, and a portable defibrillator. We saw records confirming the equipment and medicines were regularly checked. Staff had up to date training in resuscitation, basic life support and sepsis awareness.

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

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 people’s individual needs.

The practice employed a range of clinical staff. In addition to the registered provider, there were 2 salaried GPs and 4 long-term locum GPs. There was an advanced nurse practitioner, a nurse, a physician associate and a health care assistant. The practice also had an employed clinical pharmacist and a social prescriber. It shared some staff with other practices through the Additional Roles Reimbursement Scheme (ARRS), these being a clinical pharmacist, pharmacy technician and a social prescriber.

Leaders ensured staff were up to date with their training which was deemed mandatory and operated within their agreed areas of competence. From our review of staff records, we saw the practice followed safe recruitment procedures when employing staff, which were in line with national legislation. This included identity checks, a review of qualifications, obtaining references and a criminal records (DBS) check. New staff were subject to a probationary period. The DBS checks were repeated every 3 years for existing staff. We saw evidence that annual appraisals were carried out, although a few were overdue. However, we saw these were scheduled to take place.

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

The practice had logs and daily checklists demonstrating how the premises and equipment were cleaned. At our onsite visit, the premises and equipment were visibly clean. The advanced nurse practitioner was the infection prevention and control (IPC) lead, supported by the provider and practice manager. A detailed IPC audit had been conducted in November 2025. We saw that regular checks were carried out to ensure compliance and mitigate any identified risks. Staff had completed training in infection prevention and control appropriate to their roles and responsibilities.

There were arrangements in place for the management of clinical waste and there were suitable procedures for specimen collection and handling. A legionella risk assessment had been undertaken in March 2026. We saw records confirming staff carried out monthly water temperature monitoring in accordance with the risk assessment, and that regular sample analysis was conducted.

Records were maintained and monitored to ensure staff were up to date with necessary immunisations.

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