High Pastures 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 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 was located in an adapted building. Required aids, adaptations and facilities were in place to ensure the premises were accessible for all people. A small number of treatments rooms were available on the first floor but patients who required ground floor access were fully accommodated.

A range of contracts were in place for maintenance of the premises and equipment. Health and safety related policies and procedures were in place, including those related to fire safety. However, the provider had not carried out a health and safety risk assessment and actions had not been taken in a timely way in response to issues/risks identified in a fire risk assessment. Gas safety certification was also not available at the time of the assessment. This was actioned with immediate effect following our visit, alongside the higher risk fire safety required actions.

Staff had been provided with training in health and safety related topics such as fire safety, infection control and manual handling. However, this was not consistent and there were gaps in training in these areas.

There was a business continuity plan in place to provide guidance for dealing with a major disruption to the service, for example an IT failure.

The provider had reviewed and increased staffing to make sure there was sufficient number of qualified, skilled and experienced staff working at the service. The provider should also consider a review of staffing and roles and responsibilities of the leadership and management structure.

People who used the service benefited from a stable clinical team, resulting in consistent care and treatment. There were appropriate arrangements in place for covering staff sickness, absence and vacancies and the use of temporary staff was minimal.

Feedback we viewed from people who used the service was positive overall with comments indicating high levels of satisfaction with members of the staff team and with access to clinicians.

Staff told us they worked well together to provide safe care that met people’s individual needs. They told us they had protected learning time for them to undertake training, learning and professional development and they felt they had the appropriate training required for their roles and responsibilities. However, the training information showed gaps in core mandatory topics across the staff team and the provider was not routinely monitoring staff compliance with training requirements. Staff told us they were provided with the support they needed to deliver safe care and treatment. However, some of the processes in place for supporting staff were not formalised. Not all staff had undergone an appraisal in the past year and supervision arrangements were not always formalised and documented.

The service followed recruitment procedures when employing staff, which included identity checks, a review of qualifications, obtaining of professional references and a criminal records check. However, staff had not been required to provide evidence of their immunisation status. New staff underwent an induction programme and were required to undertake mandatory training.

The provider assessed and had procedures in place to prevent the risk and spread of infection. The facilities and premises were appropriate for the provision of clinical care. Personal protective equipment was in good supply and located appropriately around the premises.

There were clear roles and responsibilities around infection prevention and control with a dedicated lead person. Training records showed that some of the staff team required training in infection prevention and control.

Cleaning schedules were in place and cleaning equipment was stored securely and in line with best practice.

During our onsite visit, the premises and a sample of equipment were reviewed and noted to be visibly clean. The infection prevention and control lead conducted regular focused audits to ensure compliance and took action where necessary to mitigate identified risks.

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