The Burbage Surgery Also known as Dr Jones and Partners

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 had systems and processes in place to maintain a safe environment for people using the service. Policies, procedures and safety information were held on an electronic management system which was accessible to all staff. This included information relating to environmental safety, emergency medicines and compliance monitoring. Leaders maintained regular oversight to ensure actions identified through audits and checks were completed.
The service had arrangements in place to manage health and safety risks associated with the premises. Fire alarm tests were completed weekly and an external contractor carried out quarterly fire safety reviews. Any recommendations identified were reviewed and actioned by the service. Fire extinguishers were serviced annually, with additional monthly checks completed by staff. The service had systems to support fire safety. Staff completed fire safety training and designated fire marshals were available within the service. Regular fire drills were undertaken to help ensure staff understood their responsibilities in the event of an emergency.
Access to clinical and staff-only areas was restricted to authorised personnel. Clinical rooms were secured through swipe-card access and staff entrances were protected by coded entry systems. Temporary staff were issued with visitor access passes when required.
The service had arrangements to ensure equipment and technology remained safe and fit for purpose. Clinical equipment was routinely calibrated and maintained by external contractors, while technology systems were supported through contracted specialist providers.
The service had a business continuity plan which had recently been reviewed and updated to reflect working arrangements within the primary care network. The plan outlined how services would continue in the event of disruption and was accessible to staff electronically, with additional oversight provided through regular review.

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.
Systems were in place to ensure staff remained competent in their roles. Appraisals were completed annually, mandatory training was monitored through an electronic system, and leaders reviewed training compliance regularly. Staff also had access to protected learning time sessions and role specific training opportunities.
The service followed safe recruitment procedures, including appropriate employment and Disclosure and Barring Service (DBS) checks where required. Leaders maintained oversight of recruitment records and staff compliance.
Staffing levels and skill mix were regularly reviewed to support effective service delivery. Leaders planned workforce capacity in advance and had arrangements in place to provide additional cover where required. Staff told us they felt supported and understood their individual roles and responsibilities within the practice team.

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 Advanced Nurse Practitioner (ANP) was the infection prevention and control (IPC) lead and provided oversight of IPC arrangements within the service. Staff completed regular infection prevention and control training and refresher updates, and any changes to guidance or practice procedures were discussed at team meetings to ensure staff remained informed and up to date.

The service had systems in place to monitor staff immunisation status in line with current UK Health Security Agency (UKHSA) guidance. Vaccination information was reviewed during recruitment and recorded within staff records. Where staff had not received recommended vaccinations, individual risk assessments were completed, and appropriate measures were put in place.

Arrangements were in place to ensure infection-related concerns were reported appropriately. The service understood its responsibilities for reporting notifiable diseases and worked with external agencies, including UK Health Security Agency and occupational health services, where required. Leaders monitored infection prevention and control arrangements to help ensure risks were identified and managed effectively.

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