Bishop's Close Medical Practice

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 72 (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 provider 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 to ensure the premises was maintained. Staff told us the building was owned by NHS Property Services and that they carried out all requested repairs to the premises in good time.

Staff and leaders completed health and safety risk assessments and undertook audits to ensure they had identified and addressed all risks.

The provider had a business continuity plan which was regularly reviewed and outlined how the practice should continue to operate in the event of a disruption. This was tested in the last year when the practice had reduced power and temporarily moved to their alternative premises. This enabled them to maintain the provision of services.

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

The provider employed a range of clinical and non-clinical roles, which included GPs, nurses, healthcare assistants and pharmacists. Leaders ensured that most staff were up to date with their training which the provider had deemed mandatory and operated within their agreed areas of competence. However, the system used to monitor training compliance did not provide sufficient assurance that all mandatory training had been completed in line with relevant guidance. At the time of the assessment, the practice was in the process of implementing a purpose-built automated online training system. Following the assessment, implementation was accelerated, and the provider took prompt action to address identified gaps in mandatory training. As a result, all staff members who required additional training successfully completed the outstanding modules.

The provider followed safe recruitment procedures when employing staff, which were in line with national legislation. This included identity checks, review of qualifications, obtaining of professional references and a criminal records check. However, prior to the assessment, staff immunisation records were maintained through a manual system, which limited the provider's ability to maintain effective oversight and promptly identify any gaps in compliance with relevant guidance. The provider responded promptly to address this and subsequently collated all immunisation records into a centralised system, providing clear oversight of staff compliance with relevant guidance. Appropriate risk assessments were in place where evidence of vaccination was not available, and oversight arrangements had been strengthened, including at recruitment, to support effective ongoing monitoring. This provided assurance that appropriate systems were now in place.

The Practice is a training practice for post-graduate doctors and medical students.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

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

During our onsite visit, the provider's premises and a sample of equipment reviewed was noted to be visibly clean. The practice’s infection prevention and control lead conducted regular risk assessments and audits to ensure compliance and took action where necessary to mitigate any 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.