Church Lane 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 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.

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

The provider had contracts in place to ensure both premises (Church Lane Surgery and the branch practice at Helperby) were well maintained. Staff and leaders had completed health and safety risk assessments and undertaken audits to ensure they had identified and addressed any potential risks.

Portable appliance testing and calibration of equipment were up to date and regular fire safety checks were conducted. Most staff had completed fire awareness safety training, and those staff who acted as Fire Wardens had undertaken additional training appropriate to that role.

The provider had a business continuity plan which was regularly reviewed and outlined how they would continue to operate in the event of a disruption (such as loss of telephony or utilities, unexpected staff shortages, loss of access to buildings, security threats, and adverse weather).

Staff we spoke to on the day of our visit confirmed that they had all the equipment required to undertake their role safely and effectively. They also confirmed that they were satisfied with the health and safety arrangements at the surgery.

Although we identified that the clinical waste bin at the Helperby branch was not secure and contained clinical waste, this was immediately addressed by the practice manager during our visit.

Church Lane Surgery 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 surgery employed a range of clinical and non-clinical roles, which included the 6 GP Partners and 8 salaried GPs, a nursing team and 3 health care assistants, practice manager and assistant practice manager, administrative team, reception staff, dispensary team, and cleaning staff. Other staff worked at the surgery through Yorkshire Health Network including a social prescriber, First Contact Physiotherapists, a First Contact Mental Health Practitioner, and a Digital Transformation Lead.

Staff we spoke to on the day of our visit confirmed that, when all staff were at work, there were enough staff to provide safe, quality care and that, during periods of absence (sickness, annual leave etc.), adequate staff cover was maintained.

Leaders ensured staff were up to date with their mandatory training and operated within their agreed areas of competence. We found most training was up to date and that the learning needs and development of staff was managed appropriately. Where training had not been completed, there was a system in place to monitor this and ensure completion.

Staff received annual appraisals and supervision with, for example, GP Registrars having dedicated debrief slots at the end of each session to discuss cases and receive feedback.

The surgery followed safe recruitment procedures when employing staff, which were in line with national legislation. This included completing identity checks, a review of qualifications, obtaining professional references and a criminal records check.

It was noted however that the surgery did not always maintain complete records of staff immunisation status as per national guidelines. This issue had been identified by the provider prior to our assessment however and they were actively taking steps to address the issue – they were in the process of ensuring that all employees had their immunisation record checked, that outstanding immunisations were identified and referrals were made to occupational health where necessary, and that accurate details were retained in staff records.

Church Lane Surgery assessed and managed the risk of infection. It detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The surgery had cleaning schedules available, which outlined how staff should clean the buildings and its equipment. They demonstrated how these were monitored for completion to maintain oversight of cleaning arrangements.

During our onsite visit, both premises and a sample of equipment were reviewed and were noted to be visibly clean.

The surgery had a designated infection, prevention and control (IPC) lead and they had conducted regular risk assessments and audits to ensure compliance, acting where necessary to mitigate any identified risks.

Annual IPC training was mandatory for all staff and, at the time of our visit, most staff had completed it. For the one member of staff who had not, completion was being monitored.

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