The Spa 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 assessment, we rated this key question as good. At this assessment, the rating remains the same.

This service scored 78 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

People felt supported to raise concerns and staff treated them with compassion and understanding. Managers encouraged staff to raise concerns when things went wrong and had introduced a learning event policy that encouraged staff to raise concerns through a shared learning process. As a result of this, the practice saw an increase in the number of events raised compared to previous years. During staff meetings, the whole team discussed and learnt from clinical issues.

Staff felt there was an open culture, and that safety was a top priority. The provider had processes for staff to report incidents, near misses and safety events.

There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support.

Learning from incidents and complaints resulted in changes that improved care for others. For example, a patient was requested to provide a repeat urine test, but the results were not actioned in a timely manner. Therefore, a new urine management protocol was put in place which included the provision of a structured screening questionnaire and any results needing urgent attention were sent to the Clinical Support GP for action the same day.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

There were systems in place for processing information relating to new patients. The service worked with other providers to deliver shared care and when patients moved between services.

Staff understood their roles and had systems in place to manage tasks and test results. Through searches on the practice’s clinic system, we saw that referrals and test results were managed in a timely way and included contacting the patient following a referral to other services to ensure they received an appointment.

The practice had a data quality team to deal with document management from hospital or other providers, and we saw that these were actioned in a timely manner. New patients were required to complete a new patient questionnaire as part of the registration process which included current medication, ailments and allergies.

The service worked well with people and healthcare partners to fully understand what being safe meant to them and the best way to achieve that. They had a clear focus on improving people's lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They always shared concerns quickly and appropriately.

We found that staff had a good understanding of safeguarding and how to take appropriate action. Safeguarding policies were in place and known to staff, who were appropriately trained in safety procedures. All staff we spoke with were able to inform us who the practice’s safeguarding lead was. The practice had implemented safeguarding champions within different teams at the practice. This included within the nursing team, care navigators and within the data quality team. This ensured a consistent approach and embedded safeguarding procedures across the practice.

The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations. The practice had multi-disciplinary meetings with other agencies such as health visitors, and district nurses to discuss patient safety issues. The practice ran regular reports for when patients left the practice to join another. If there were any safeguarding concerns then the safeguarding lead would provide a verbal handover to the new practice. The practice also ran regular reports to monitor children not brought for appointments within primary and secondary care, and also patients who were high attenders at accident and emergency. The provider had also developed links with local charities and schools in order to share information and learning around safeguarding.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Emergency equipment was available and maintained. Staff could recognise a deteriorating patient and knew of action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

Staff had received training in basic life support and were able to explain how to act safely in an emergency, including alerting clinical staff and the emergency services.

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

During the assessment the practice could not provide details of when portable appliance testing (PAT) had been carried out. After the assessment the provider confirmed that PAT testing would be completed in March 2026. They had a risk assessment policy which outlined that PAT testing was undertaken 5 yearly with high-risk items being tested annually. We saw evidence that high risk items had been tested on 17 September 2025.

Health and safety risk assessments and audits had been undertaken and risks identified had been addressed. There was a business continuity plan in place which was monitored and reviewed. We saw that staff had completed mandatory training in fire safety.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked well together to provide safe care that met people’s individual needs.

There were a range of clinical and non-clinical roles within the practice including a social prescriber, data quality team, first contact physiotherapists, pharmacists and memory support advisor.

We found training was up to date, learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence.

As part of this assessment, we looked at recruitment files of 4 members of staff. Most files recorded that appropriate recruitment checks had been completed and staff had received annual appraisals. Professional registrations were not always checked on an ongoing basis. During the assessment the practice updated their recruitment procedures to include annual professional registration 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 practice had a designated infection, prevention and control lead (IPC) and all staff had had relevant training. Cleaning schedules were in place and followed. Risk assessments and audits were completed. The nurse who was the IPC lead was given dedicated time to carry out the role.

We observed the practice to be clean and tidy throughout with relevant equipment and building checks.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

Staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely. People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms.

Staff received regular training, were competency assessed on medicines optimisation, and felt confident managing the storage, administration and recording of medicines. Staff managed prescription stationery appropriately and securely. Staff followed protocols to ensure they prescribed all medicines safely, and ensured people received all recommended medicines reviews and monitoring.

Searches ran on the practice’s clinical system indicated that 2 patients with hypothyroidism out of 639 had not had the required monitoring. Upon further review it was noted that these patients had been invited for blood test but neither patient had responded.

Searches indicated 21 out of 88 patients had not had recommended monitoring of diuretics used generally in heart failure. Review of 5 patient records confirmed that blood tests were overdue for all 5 patients. This was reviewed by the practice. When we carried out our site visit, all 5 patients had been reviewed.

Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments. The provider had effective systems to manage and respond to safety alerts and medicine recalls. Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring.

Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. Prescribing data reviewed as part of our assessment confirmed this. For example, the number of antibiotic items prescribed by the provider was slightly lower than national averages.

There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.