S H Vaghela & Dr V N Patel Also known as The Old 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, we focused on 3 quality statements relating to the key question Safe: Safe environments, Safe and effective staffing and Infection prevention and control (IPC).

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

The practice had arrangements in place to ensure the premises was maintained. Staff and leaders completed health and safety risk assessments and undertook audits to ensure they had identified and addressed all risks.

Potential risks in the care environment were well-managed. The premises were small and single storey, with two consultation rooms. They were re-decorated recently, with new floor covering suitable for a healthcare setting being laid.

A Fire Safety risk assessment had been carried out in November 2025. Extinguishers had been inspected and certified. Emergency lighting had been installed recently. We saw records confirming regular fire alarm testing was carried out and fire drills conducted. Portable appliance safety testing (PAT) had been completed in December 2025, together with equipment calibration.

The practice had up to date policies covering health, safety and welfare. We saw evidence of staff completing training in fire safety, health and safety and, where relevant, legionella awareness.

The practice had a detailed business continuity plan which was regularly reviewed and outlined how the service should continue to operate in the event of a disruption.

The practice 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 practice employed a range of clinical and non-clinical roles, which included GPs, 2 of whom were long-term locums, 2 locum advanced nurse practitioners and a healthcare assistant. A pharmacist and a social prescriber were shared with other the practices in the primary care network. We saw the practice’s locum pack which provided locum staff with information regarding the practice’s working processes and governance, together with local procedures.

Leaders ensured staff were up to date with their training which was deemed mandatory and operated within their agreed areas of competence. From our review of staff records, we saw the practice followed safe recruitment procedures when employing staff, which were in line with national legislation. This included identity checks, a review of qualifications, obtaining references and a criminal records check. New staff were subject to a probationary period, and we saw evidence that annual appraisals were carried out.

The practice had appropriate equipment and medicines for use in medical emergencies. These included an oxygen supply, with suitable fittings for children, and a portable defibrillator. Appropriate risk assessments had been carried out in relation to the emergency medicines. Staff had up to date training in resuscitation, basic life support and sepsis awareness.

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

The practice had logs and daily checklists demonstrating how the premises and equipment were cleaned. At our onsite visit, the premises and equipment were visibly clean. The practice’s healthcare assistant was the infection prevention and control lead, supported by the lead GP and nursing staff. They conducted regular checks to ensure compliance and acted where necessary to mitigate any identified risks. Staff had completed relevant training in infection prevention and control appropriate to their roles and responsibilities. During the assessment, we were told a new senior nurse, who would take over the lead IPC role at the practice had been appointed and would be starting work imminently.

There were arrangements in place for the management of clinical waste and there were suitable procedures for specimen collection and handling. A legionella risk assessment had been carried out in November 2025. We saw records confirming staff carried out monthly water temperature tests, having received additional legionella awareness training.

Records were maintained and monitored to ensure staff were up to date with necessary immunisations.

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