Friary House 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 people were protected from abuse and avoidable harm.

This is the first inspection for this service under a new provider with CQC. We assessed all quality statements in the safe key question. This key question has been rated as good.

At this assessment, we found safe recruitment systems in place and effective systems to help protect people from abuse and neglect. People’s care and treatment were delivered in line with current guidance and evidence, and by staff who had the required skills, knowledge and experience. Staff were knowledgeable within their roles and shared experiences to support development. The facilities and equipment met the needs of people and were clean and well maintained.

However, the service did not always make sure that people could access the care, support and treatment they needed when they needed it. The National GP Patient Survey data showed lower than average positive results for accessing the practice.

Systems relating to freedom to speak up needed enhancing to promote a culture of openness within the practice team. Improvements were needed in reporting and investigating incidents and significant events. Learning from investigations was not effectively shared with staff, and systems and processes were not consistently reviewed and developed to improve services.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Managers encouraged staff to raise concerns when things went wrong. Staff told us there was an open culture for reporting incidents, but did not always feel assured that safety was a priority. For example, when the lack of staff impacted services provided to people.

The provider had processes for staff to report incidents, near misses and safety events. However, there was a disparity between the Central Office and the service as to how significant event reporting was managed. Staff told us the practice manager dealt with these, as stated in the practice policy. However, we were also told by managers that the Central Office investigated these, and reports were sent there for this reason. We reviewed the significant event records and saw that no entries had been made since July 2024. Therefore, significant events were not always identified or investigated, and lessons were not always learnt to identify and embed good practice.
 

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. There were systems in place for processing information relating to new patients. The service worked with other providers to deliver shared care and when people moved between services. Referrals and test results were managed in a timely way.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

There were safeguarding policies that were known to staff, who were appropriately trained in safeguarding procedures. There were designated safeguarding leads at the practice who attended multi-disciplinary meetings.

The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations. A review of safeguarding records showed that alerts were appropriately placed on peoples records and those of household family members.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff understood the procedures for acting on safety alerts and the checks they would make to ensure action was taken, we saw this was followed.

Emergency equipment was available and maintained. We found appropriate emergency equipment and medicines were kept at the service and systems for checking emergency equipment and medicines were effective.

We reviewed staff training records for sepsis awareness and all frontline staff had completed this training. Staff could recognise a deteriorating patient and knew of action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

The service did not always detect and control potential risks in the care environment.

During our site visit, we identified areas which required maintenance. We were told by the leaders that repairs to the premises had been recognised and when finances were approved, they would be completed. For example, rusting fire escape stairs, rusting supporting pillars to the front of the practice and peeling paint internally. However, there was no documentary evidence available to support this. Following our onsite visit, it was confirmed that a fabricator had been contacted to visit the practice and quote for the work required on the emergency exit.

We found windows on the first floor were able to be fully opened as there were no window restrictors in place, the service immediately addressed our concerns and provided us with evidence to demonstrate action had been taken.

Equipment was fit for purpose and maintained to ensure it was in good working order. Clear signage around the building supported people and staff in the event of an emergency evacuation. Contracts with external companies ensured the premises were maintained. Health and safety risk assessments had been carried out and where necessary, appropriate actions taken.

The practice had not carried out emergency lighting and fire alarm checks in line with their fire safety policy. We found fire alarm checks should have been completed weekly however, we saw that these were carried out at 2 and 3 weekly intervals.

The emergency light testing was last carried out in March 2025 but the fire safety policy states this was to be completed monthly.

The service did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. This did not meet the practice’s vision of “To be a practice that performs outstanding primary care in line with our patients needs and at the highest level of patient satisfaction. As a practice we’d like to attract, reward and retain highly skilled staff and help them grow in their careers to the best of our ability”.

Existing staff worked together well to provide safe care. However, access to appointments was limited and feedback from patients was negative in relation to being able to access timely appointments.

We found training was not always up-to-date, learning needs and development of staff was not always managed appropriately and clinical supervision was not being routinely maintained. We saw that staff were working within their agreed areas of competency. Records of competency checks were not being maintained on a regular basis. However, this had taken place historically but due to the GP responsible for the completion of clinical supervision leaving this was now being shared between the 2 remaining GPs.

Staff told us they felt there were not enough staff to manage workloads of activity. However, rotas were completed with oversight of cover where required, so if a clinician was absent at short notice, their pre-booked appointments could be put into a protected available same day slot with another clinician or remote support offered. There were remote staffing arrangements to ensure in the event of an emergency, the risk of unsafe practice was mitigated to prevent lone working.

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. The service had a designated infection, prevention and control lead and all staff had completed relevant training. The premises we visited was visually clean. Cleaning schedules were followed by an external company.

Risk assessments and audits were completed, and actions taken to mitigate risks. Sharps bins inside the premises were appropriately managed. Personal Protective Equipment (PPE) was available to staff. There was a process to record staff vaccinations in line with national guidance.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

Staff managed prescription stationery appropriately and securely. Staff followed protocols to ensure they prescribed all medicines safely.

We reviewed a sample of Patient Group Directions (PGDs) (a written instruction for the supply and/or administration of a named licensed medicine for a defined clinical condition by named registered health care professionals without them having to see a prescriber) and Patient Specific Directions (a written instruction from a doctor or other independent prescriber for a medicine to be supplied or administered to a named patient) and found they had been completed correctly in line with guidance.

Medicines were stored securely and the service held appropriate emergency equipment and emergency medicines. The service maintained fridge temperature records where vaccines were being stored. We were told by staff that there were periods of time when childhood immunisations and travel vaccines supplies were low and people were unable to book appointments for these. On the day of our site visit, we found the practice had recently received a supply of vaccines and immunisations on 16 July 2025. However, the number of supplies were not sufficient to meet demand. For example, there were 7 typhoid vaccines which would not cover the summer period when people were likely to travel abroad and required this vaccine. We raised this with leaders following the site visit and they advised us that travel vaccines are ordered on a patient demand-led basis to minimise clinical waste as these vaccines have limited shelf life.

The service had developed a process for patients requiring Depo-Provera injections (which are a form of hormonal contraception that provides long-lasting protection against pregnancy) due to a lack of supplies being ordered/received. The process meant that patients were provided with a prescription for this medicine, which once dispensed they would be required to take with them to their appointment. However, staff told us that this process wasn’t always effective, as patients did not always remember to bring the medicine or requested the prescription with not enough time to ensure they were fully protected. Therefore, the risk of unplanned pregnancy was increased.

As part of our inspection, a number of set clinical record searches were undertaken remotely by a CQC GP specialist advisor. These searches were visible to the practice. The clinical searches identified patients who had been prescribed high-risk medicines and had been appropriately monitored and reviewed in line with national guidelines. We also found patients who were affected by medicine safety alerts had been contacted and informed of the risks, and prescriptions were reviewed appropriately.