Worden Medical Centre

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 has changed to requires improvement. The service is in breach of legal regulations in relation to fit and proper persons employed.

This service scored 59 (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 did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

Environmental safety was not a priority for the service. The most recent fire risk assessment had been carried out in July 2023. A fire drill was carried out in the same month, and this had not been repeated since. In January 2023 the fire service had written to the service to inform them some improvements were required. These included ensuring combustible materials were not kept close to ignition sources, for example in boiler rooms. The service had 2 boiler rooms, and both were used for storage, including for combustible material. The service told us they carried out fire alarm checks weekly, but they had only been carried out 15 times since 1 January 2026. The monthly emergency lighting tests had been carried out 4 times since 1 January 2026.

The most recent health and safety risk assessment had been carried out in June 2020.

The security of prescription stationery was not adequate. It was not possible to determine what prescriptions were kept where, and who had had access to them. In addition, the service had a supply of 13 pads for handwritten prescriptions. These were not recorded anywhere.

The service did not make sure there were enough qualified, skilled or experienced staff. We examined the personnel records of 4 staff who had been employed in the previous 12 months. The service did not hold all the required information for any of the 4 staff. Disclosure and Barring Service (DBS) certificates were not always checked before staff, including GPs, started work. Evidence of identity, including a recent photograph, was not always kept. The practice manager confirmed they did not ask about gaps in employment histories, or the reasons why people left employment involving work with children or vulnerable adults. Some new staff had been known by other staff in the practice, and the manager confirmed all the required checks had not been carried out for them. The service confirmed that although they checked that clinicians were registered with the appropriate body, for example the General Medical Council (GMC), they never checked that GPs were included in the GP Performers List. This is the register of GPs authorised to work in NHS general practice. The practice manager told us they checked that locum GPs were registered with the GMC, but they did not carry out any other check, such as an identity check, and they did not ask for confirmation they were up to date with mandatory training, such as safeguarding.

Training for permanent staff was monitored, and we saw the majority of training was up to date. Appraisals were carried out annually and these were also mostly up to date.

The service did not consistently assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

The service had cleaning schedules available, which outlined how staff should clean the building and its equipment. The service demonstrated how these were monitored for completion to maintain oversight of cleaning arrangements. During our onsite visit, the service's premises and a sample of equipment reviewed was noted to be visibly clean. The service’s infection prevention and control lead conducted regular risk assessments and audits to ensure compliance and took action where necessary to mitigate any identified risks. However, hand wash audits did not always indicate who had been checked, so it was not possible to see who was compliant. Also, the vaccination status of staff was not held or requested. Staff had completed relevant training in infection prevention and control.

The service had a series of policies relating to infection prevention and control. However, there was no overarching policy to indicate who the lead was, who local contacts were, what training was required for staff and what audits should be carried out.

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