Fryern 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.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The service operated from a large multi-storey building and had arrangements to support the safe movement and evacuation of people with mobility difficulties. This included access to ground-floor consultation rooms, an evacuation chair. Lift servicing and maintenance records were completed. Fire safety arrangements, including evacuation procedures, alarm testing, emergency lighting checks and staff training, were completed in line with the service’s policy and monitored by leaders.

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

Portable appliance testing (PAT) and equipment calibration had been completed in December 2025 and were routinely monitored. The service had a fire evacuation plan and policy, and fire training had been completed by the appropriate members of staff. Scheduled safety checks were conducted on the fire alarm system, emergency lighting and equipment.

The service 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 service employed a range of clinical and non-clinical roles, which included GPs, nurses, health care assistants and pharmacists. Leaders ensured staff were up to date with their training which the service had deemed mandatory and operated within their agreed areas of competence. The service followed safe recruitment procedures when employing staff, which were in line with national legislation. Our review of 2 staff files showed completed identity checks, review of qualifications, obtaining of professional references and a criminal records check (DBS). All gaps in employment were documented in detail and full records of all immunisations were held.

Leaders invested in developing staff skills and supporting internal career progression. For example, a care co-ordinator had been upskilled to become a phlebotomist, and another care co-ordinator had become a social prescriber.

Daily huddles provided opportunities to discuss operational and clinical matters, while duty GPs and team leads were available during clinical sessions. In addition to daily informal supervision and support, staff received regular appraisals and structured check-ins. Appraisals were completed annually, with additional three-monthly wellbeing and development discussions. Records reviewed confirmed appraisal and supervision arrangements were in place for both clinical and non-clinical staff.

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. Staff had completed relevant training in infection prevention and control as part of their induction.

The service had a designated infection prevention and control lead (IPC), and staff were aware of who this was and how to escalate any concerns. Personal protective equipment (PPE) was appropriately stocked, and accessible, clinical equipment was maintained in a clean condition and spillage kits were available if needed.

The service had cleaning schedules available, which outlined how staff should clean the building and its equipment. The service demonstrated how this was monitored and maintained oversight of cleaning arrangements.

The IPC lead carried out regular audits and risk assessments to monitor compliance. Records included legionella risk assessments and water temperature testing. Leaders took action to mitigate identified risks. For example, following an IPC audit, the service added the deep cleaning or replacement of fabric chairs with wipeable alternatives to its ongoing maintenance plan.

The service demonstrated appropriate arrangements for the management of clinical waste and sharps. Leaders were also aware of an ongoing issue relating to the security of external waste bins and had escalated concerns to the waste contractor. They were actively seeking advice and exploring options to identify a sustainable solution.

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