Maidstone Road Rainham 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, 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 did not always detect and control potential risks in the care environment. They did not always make sure facilities supported the delivery of safe care.

The service conducted a fire risk assessment in January 2026. The assessment identified the front door to the service, that also served as a fire exit, opened inwards; however, no actions had been recorded to demonstrate how this risk was being mitigated. During assessment, we identified the rear fire exit opened inwards and had a step leading to the outside. This could impact evacuation pathways for people who were not able-bodied. This had not been identified in the fire risk assessment conducted in January 2026. However, staff had completed annual fire safety training and the service carried out regular fire drills, with the most recent taking place in February 2026, to support compliance with safety protocols. Records demonstrated fire alarms and emergency lighting were tested regularly.

Following assessment, the service reviewed and updated its fire risk assessment and fire evacuation procedures. They confirmed that a ramp had been ordered to support safer evacuation and notices had been placed on fire doors advising the direction that they opened.

The service could not demonstrate they had identified all risks associated with their premises in relation to Legionella. They had not conducted a Legionella risk assessment and did not monitor water temperatures. However, the service took water samples in July 2025 which showed no Legionella growth at that time.

Following assessment, the service confirmed that they had made arrangements for a contractor to carry out a Legionella risk assessment on 25 June 2026.

A health and safety risk assessment had been completed in January 2026. Risks had been identified and resolved. For example, ensuring trip hazards were removed in public areas.

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

Contracts were also in place to ensure the premises and equipment were maintained. For example, portable appliance testing and equipment calibration were routinely conducted by an external company.

The service had not ensured that recruitment processes were consistent and well documented. However, there were enough qualified, skilled and experienced staff, who received support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

We reviewed a sample of 6 recruitment files and found 3 did not have proof of identification or references recorded within their files. We saw that Disclosure and Barring Service (DBS) checks had been completed for staff.

Following assessment, the service told us they would undertake a retrospective review of all staff records to ensure they were complete and appropriately documented. The service confirmed references had historically been obtained, but due to administrative changes and inaccessible email accounts, documentary evidence was not readily available.

However, there were a range of clinical and non-clinical roles at the service. We reviewed a sample of 6 staff training records and saw all staff had received training appropriate to their role.

The service told us they carried out informal competency checks. Audits were undertaken by senior staff to assess whether staff were working safely and within their scope of competence. Following assessment, the service provided an audit template they intended to implement to formalise these competency checks.

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.

The service had a designated infection, prevention and control (IPC) lead and all staff had received relevant training. The service conducted an IPC audit in July 2025; the assessment identified risks that required action, including the need to escalate concerns relating to the general repair and condition of the building. Leaders told us this concern had been escalated.

Staff vaccination was maintained in line with current UK Health and Security Agency (UKHSA) guidance.

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