Balmoral 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

The safe key question remains rated as good. We assessed 2 quality statements to follow up on information of concern: safe environments and infection prevention and control. We found the provider had systems and processes in place to detect and manage potential risks in the care environment. We also saw there were systems to help assess and manage the risk of infection. During the site visit, we found the practice had maintained appropriate standards of cleanliness and hygiene.

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.

Leaders we spoke with explained how they had oversight of tasks and processes to ensure they detected and controlled risks in the care environment. Designated staff members were responsible for completing tasks such as health and safety, and fire risk assessments. Risk assessments were shared with relevant leaders and staff. Any specific learning from risk assessments were also shared with staff via staff meetings and emails to facilitate improvements. Staff and leaders we spoke with told us the practice had a strong team ethic and worked well together. Staff said they felt able to raise concerns without fear of retribution. For example, staff identified an area of improvement regarding the storage of the emergency medicines and equipment. Staff told us leaders were receptive to the ideas and changes were implemented.

The practice had an up-to-date staff immunisation policy and we saw evidence that staff had received vaccinations in line with this. All staff had completed annual fire safety training online and every 3 years they attended in-house fire safety training. We saw the practice conducted fire alarm and emergency lighting checks and commissioned an external company to service the fire extinguishers. The practice held appropriate emergency medicines. Risk assessments were in place to determine the range of medicines held and a system was in place to monitor stock levels and expiry dates. The practice was equipped to respond to medical emergencies. There was medical oxygen and a defibrillator on site. We saw there were systems to ensure these were regularly checked and fit for use. All medicines and equipment we checked were in date and stored securely.

Fire drills and fire alarms were regularly tested at the practice. Portable appliance testing and calibration testing of equipment had been carried out in the last 12 months. Risk assessments we reviewed identified potential hazards to individuals and the provider had implemented improvements to address concerns. For example, removal of clutter. We reviewed the training records of 6 staff members designated as fire marshals and found 3 were overdue a fire marshal refresher course. After the assessment, the provider told us there was a waiting list for this training. The provider sent us evidence showing they had instructed the staff members to add themselves to the waiting list.

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

The provider told us they had conducted a deep clean of the practice prior to our site visit and that deep cleans occur when required. We saw the practice's cleaning schedule which outlined specific cleaning requirements. A designated staff member supervised this process and addressed any issues with the external cleaning company. When there were concerns about cleaning standards, we saw evidence that this was communicated to the cleaning company and a plan introduced to improve standards. The provider conducted spot checks of the premises. Leaders told us there was no formal schedule for these checks but that they would occur as a follow up action from infection prevention and control audits, particularly when concerns were identified. Staff told us there was an open culture and they had the opportunity to raise any issues and felt confident and supported in doing so. For example, staff identified that floors did not appear to be cleaned to a high standard. This was referred to the cleaning company and improvements were made.

During our site visit, we observed 11 clinical rooms. We saw the practice had maintained appropriate standards of cleanliness and hygiene. The arrangements for managing waste and clinical specimens kept people safe. We saw sharps bins were managed in line with guidance. We saw that cleaning schedules and Control of Substances Hazardous to Health (COSHH) risk assessments were maintained and checked by the provider. There was an up to date cold-chain policy (the system of transporting and storing vaccines within the recommended temperature range). Vaccines were appropriately stored and monitored in line with UK Health Security Agency (UKHSA) guidance to ensure they remained safe and effective.

We reviewed training records of 14 staff members and saw they had received appropriate training in infection prevention and control (IPC). There was an up-to-date IPC policy. The provider had a rolling programme of conducting IPC audits. This included general cleanliness of the premises, correct usage of sharps bins, ensuring hand washing posters were displayed, whether personal protection equipment were available in rooms, and whether equipment and the premises were in good condition. An IPC audit was completed in June 2024 and an action plan was implemented to address issues identified. For example, the audit identified 3 sharps bins which had not been managed in line with guidance, and 2 treatment rooms which were not free from clutter. We saw evidence the provider had communicated to relevant staff regarding these issues and that spot checks had been conducted to ensure appropriate action had been taken. During our inspection, we saw clinic and treatment rooms to be free from clutter. The provider shared evidence to show they planned to conduct another spot check to ensure that all rooms were maintained to the necessary standard.

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