Calder View Surgery Also known as Calder View 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 have rated the practice as good for providing safe services. We looked for evidence that people were protected from abuse and avoidable harm. The practice had a good learning culture, staff could raise concerns, and managers investigated incidents thoroughly. There were systems in place to ensure people were safe and safeguarded from abuse. Staff understood and managed risks. The facilities and equipment met the needs of patients and were clean and well-maintained. Staff had the right skills, qualifications and experience. Managers made sure staff received training and regular appraisals to maintain high-quality care. There were systems and processes in place to support medicines management. A review of patient clinical records found that overall patients’ medicines and treatment were safely managed by the practice.

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.

The practice demonstrated a proactive and positive culture of safety, based on openness and honesty. Leaders told us that they promoted a culture of learning and encouraged staff to report incidents openly. Staff were able to explain the process of how they would report an incident or who they would seek guidance from to do so. They told us they were encouraged to report incidents and felt confident to do this. The practice had systems and processes in place, underpinned by policies, to formally manage incidents and complaints. At this assessment we reviewed a selection of incidents and complaints and saw appropriate action had been taken and learning shared through meetings.

The practice had formal systems and processes in place to manage referrals, clinical correspondence, pathology results and medical record summarising. We observed that urgent 2-week wait cancer referrals were dealt with appropriately and a system was in place to ensure they were sent in a timely manner and that patients had attended for their appointment. Pathology results were actioned by clinicians and there was a system in place for when staff were absent. We saw incoming patient correspondence was appropriately managed and actioned, including changes to patients’ medications which was undertaken by the pharmacy team. Clinical records of new patients were mostly received by electronic transfer. Those that were received in paper form were summarised in the practice’s clinical record system. We saw that the practice had summarised 83% of patient records. At the time of the assessment, the practice had not completed a formal audit of the summarising process but advised us that they would add this to their audit schedule to ensure medical records were summarised in line with their policy.

The practice had systems and processes in place to identify, record and action safeguarding concerns, which were outlined in a safeguarding policy. There was a clinical safeguarding lead and deputy for children and adults. All staff we spoke with, and those who had completed questionnaires, knew who the safeguarding leads were and how to access safeguarding policies.

Records showed that all staff had undertaken training for safeguarding children and adults at a level relevant to their role. In addition, staff had undertaken preventing radicalisation, modern slavery, female genital mutilation (FGM), domestic violence, learning disability and autism awareness training. Staff we spoke with confirmed they had undertaken training and were able to give examples of how they would report and escalate safeguarding concerns.

We saw there were systems in place to follow-up on children with frequent attendance at accident and emergency, and when children had not been taken to secondary care appointments or for childhood immunisations. There were systems in place to identify vulnerable patients on their clinical records and staff were aware of this.

The safeguarding lead attended external Kirklees safeguarding meetings and had regular multidisciplinary meetings where safeguarding was discussed and documented.

Staff who acted as a chaperone were trained for the role and had received a Disclosure and Barring Service (DBS) check. At our on-site inspection we observed notices displayed in the practice to advise patients that a chaperone service was available, if required.

Staff were confident in the systems and processes to respond to medical emergencies. Non-clinical staff demonstrated they were aware of ‘red flag’ presenting complaints, for example patients with shortness of breath, and what action to take if they encountered a deteriorating or acutely unwell patient.

At our on-site visit, we observed that the practice was equipped to respond to medical emergencies, including suspected sepsis. The practice had undertaken a review of the emergency medicines available at the practice based on local context and the services they provided. A risk assessment had been undertaken to support these decisions. There was an independent pharmacy located within the shared healthcare premises. We reviewed processes around the management of emergency equipment and medicines and saw there were regular checks in place, which were recorded.

Records confirmed that all staff had completed adult, child and infant basic life support training, which included anaphylaxis and the use of an automated external defibrillator (AED). All staff had completed sepsis training relevant to their role.

Staff feedback demonstrated that all staff were aware of the location of the emergency medicines and medical equipment, for example oxygen and the AED. Staff were aware of how to raise the alarm in the event of an emergency and told us they used the panic alarm system integrated into their clinical system.

The practice was located in a purpose-built medical facility, which it shared with another GP practice, community services and an independent pharmacy. Patient services were delivered from the ground floor. The facility was managed by the landlord who was responsible for overall premises maintenance and building risk assessments. During the assessment, we found appropriate maintenance contracts and risk assessments were in place and saw documentation for the fire alarm system, fire extinguishers, emergency lighting, portable appliance testing (PAT), calibration of medical equipment, gas safety certificate, Electrical Fixed Installation Condition Report (EICR) and Lift Operations and Lifting Equipment Regulations (LOLER). Risk assessments had been undertaken for fire, health and safety, Control of Substances Hazardous to Health (COSHH) and Legionella.

There was a record of weekly fire alarm testing, and a fire evacuation drill had been undertaken in July 2025. All staff undertook annual fire awareness training and there were nominated fire marshals, who had been trained. There was appropriate signage in place, such as for fire escape routes and the fire assembly point.

As part of our on-site assessment, we reviewed 3 clinical and 1 non-clinical staff recruitment file and found all relevant employment documentation in accordance with regulations were in place. For example, photographic identification, references, Disclosure and Barring Service (DBS) and professional registration checks.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. We saw that the practice supported the upskilling of staff. For example, we saw that some staff members had been supported with training to become nursing associates.

We found all staff were up-to-date with mandatory training identified by the practice and there were records of role-specific training. For example, cervical screening and immunisation. We saw that staff who had been at the practice for more than a year had received an appraisal. The practice had undertaken some consultation and prescribing audits of staff employed in advanced clinical practice, for example prescribing nurses, which were presented at clinical meetings for peer learning. However, this was not a formalised system. Immediately after the assessment, the practice updated their audit schedule and implemented a written protocol to formally audit and document consultations and prescribing for individual staff, including primary care network (PCN) staff.

A folder was available to locum GPs to provide them with the necessary information to carry out their role safely.

Feedback from managers and staff informed us that they had a good understanding of Infection Prevention and Control (IPC). There was a nominated IPC lead and policies in place. Staff knew who the nominated IPC lead was, how to access relevant polices and had received IPC training relevant to their role. The practice undertook regular IPC audits, and we saw that identified remedial actions had been completed.

The practice had a system in place to capture the immunisation status of staff at the point of recruitment and referred staff to their occupational health provider when updates were required.

On the day of the on-site assessment, we observed the premises to be clean, tidy and clutter-free. The cleaner’s cupboard was tidy and contained appropriate colour-coded equipment and cleaning materials. The arrangements for managing waste and clinical specimens kept people safe. We found posters around the practice including sharps injury, handwashing and clinical waste to support good practice. Appropriate personal protective equipment and bodily fluid spillage kits were available to staff. We spoke with the nominated IPC lead who told us they had dedicated time to undertake this role and had undertaken additional external training to support them in the lead role.

The practice had systems, processes and policies in place to support medicines management. As part of our assessment, a CQC GP specialist advisor (SpA) conducted a series of remote clinical searches of patient records to assess the practice’s procedures around prescribing and medicines management. These searches included patients prescribed disease-modifying antirheumatic drugs (DMARDs), medicines which required patient monitoring, medicines subject to a patient safety alert, medicines usage and medicines reviews. Overall, we found systems in place to ensure patients were managed in line with guidance. We highlighted 2 patients from the search for further review and received written feedback from the practice.

In particular, we found 30 prescribed the DMARD Methotrexate, of which none were overdue monitoring. However, we did note the day of the week on which this medicine should be taken was not included on the prescription, in line with guidance. After the assessment the practice confirmed that they had discussed this with the team, were contacting all patients to rectify this and had changed their protocol to ensure this was included going forward.

We reviewed the systems and processes in place to receive, disseminate and act upon patient safety alerts. Overall, the findings of our clinical searches indicated a structured approach.

There was a process in place for the safe handling of requests for repeat medicines and evidence of medicines reviews for patients prescribed repeat medicines.

At our on-site visit, we found vaccines were appropriately stored, monitored and transported in line with guidance to ensure they remained safe and effective. Medical gases, such as oxygen, were stored safely with appropriate warning signage. Staff had the appropriate authorisations to administer medicines, including Patient Group Directions and Patient Specific Directions. Blank prescription stationery was securely stored, and their use was monitored in line with national guidance.

Data showed that the practice had systems in place to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. We saw that prescribing outcomes were broadly in line with average outcomes.