Churchill Medical Centre

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 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 in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The main surgery premises at Churchill Medical Centre had undergone an extensive refurbishment and the environment had been updated and improved.

The service had maintenance contracts and carried out health and safety risk assessments and audits, including fire safety and legionella. However, we identified some fire safety signage had not been replaced after the refurbishment and there was no oxygen hazard sign displayed at the Churchill site. We also saw an outdated emergency lighting test log (last completed May 2024). The service provided evidence that it took immediate action to address these concerns to keep people safe.

The premises at the Ching Way site was owned by NHS Property services managed by a facilities company who had carried out a fire risk assessment and health and safety risk assessments for the building, to ensure they were properly maintained. The practice provided evidence of annual portable appliance testing, and calibration of equipment for both practice sites. The service had a business continuity plan for the main surgery site which was regularly reviewed and outlined how the service should continue to operate in the event of a disruption. There was an NHS Property Services business continuity plan for the Ching Way Medical Centre site.

Systems to manage staff training were not always effective. At the time of the assessment, leaders told us they were currently migrating recruitment and training records on to a document management platform. However, this electronic platform had been introduced 2 years ago and work was still ongoing.

A review of 5 staff records found 3 members of staff did not have employment references or identity checks. Although 5 staff members whose files we checked had completed hepatitis B and MMR screening and vaccination, there was no record of other routine immunisations. There was no evidence of mandatory training for 3 members of staff, for example, basic life support, fire safety, information governance, mental capacity and equality and diversity or record of annual appraisals. Following our inspection, evidence was provided to show that mandatory training was completed, and references and photo ID had been obtained for those staff whose records were incomplete. Managers told us immunisation history was recorded for all 5 staff mentioned and there was a record of annual appraisal documented for the 3 members of staff. Leaders told us recruitment procedures had been reviewed to ensure ongoing compliance in these areas.

Where people had specialist needs, we found most staff had received training on how to support autistic people and people with a learning disability. Clinical staff and non-medical prescribers received support and supervision meetings which were appropriately documented.

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. We observed the facilities and premises were visibly clean, and systems were in place to prevent the spread of infection. Personal protective equipment (PPE) was well stocked and placed appropriately throughout the building. The provider assessed and managed infection risks, with clear roles assigned, including a dedicated lead for infection prevention and control. Staff had received IPC training relevant to their roles.

Cleaning schedules were in place, and regular infection control and cleaning audits were conducted to maintain standards. The provider had created a new purpose-built storage space so cleaning equipment could be stored safely and according to best practice. Waste, sharps, and clinical specimens were managed carefully to keep everyone safe. However, we found staff vaccinations were not kept up to date in line with the latest UK Health Security Agency (UKHSA) guidance. There was a clear system for reporting infection concerns to the relevant agencies, such as for notifiable diseases.

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