Summervale 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 people were protected from abuse and avoidable harm. At our last assessment, we rated this key question as good. At this assessment, the rating remains the same.

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.

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 had systems and processes to detect and control potential risks in the care environment and ensure equipment, facilities and technology supported the delivery of safe care. However, we identified they were not always effective and some improvements were required.

The service had contracts 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 risks. However, we identified some shortfalls in the completion and storage of risk assessments. We viewed a sample of these risk assessments and found a risk assessment for driving a company vehicle, but we were informed there was no company vehicle. We also found a risk assessment for a named member of staff containing confidential information located in the health and safety risk assessments file on a shelf. A risk assessment to address the cleaners accessing the dispensary had not been completed. Following the inspection, the service took action to remove these risk assessments.

The legionella risk assessment identified daily monitoring of water temperatures was required to manage the risk of legionella. This was being carried out by a member of staff, however, during the onsite visit, we identified it was not happening when this member of staff was away from the business. This risk assessment also identified remedial actions that were required. Following the onsite visit, the service implemented a new system to ensure daily water temperature checks would be carried out.The service provided us with evidence that some remedial actions had taken place, but records were not clear to ensure each action had been addressed.

The service had a business continuity plan which was regularly updated and outlined how the service should continue to operate in the event of a disruption. During the onsite visit, the computer system encountered a problem, and the business continuity plan was enacted. We were told this had happened on previous occasions. This problem was soon rectified, and we were told it had not impacted the delivery of services due to the effective business continuity plan.

During the onsite visit, information relating to staff and someone using the service was left on a printer in a treatment room. The service addressed our immediate concern by removing the documents.

We found the crash trolley that contained emergency medicines and equipment adjacent to the examination couch in a treatment room, potentially compromising the privacy and dignity of someone having an examination on the couch. This was discussed during the onsite visit, and the service relocated this trolley to the other side of the room. We also found gaps in the recording of daily checks of emergency medicines and monthly emergency equipment checks. Following the onsite visit, the service took action to address our concerns.

The service had systems and processes in place to make sure there were enough qualified, skilled and experienced staff. However, they were not always effective. They did not always evidence staff received effective support, supervision and development. Staff worked together 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, and dispensers.

Leaders ensured staff were up-to-date with their training which the service had deemed mandatory. We were told staff operated within their agreed areas of competence. However, although we saw supervision notes, there was no recorded evidence competencies had been assessed. Following the onsite visit, the service addressed our concerns and implemented a new process, which required time to be embedded to ensure they were effective.

The service had a policy to follow safe recruitment procedures when employing staff. However, during our onsite visit, we reviewed 3 staff files and found all were missing some of the evidence required in line with legislation. For example, 1 staff file for a non-medical prescriber was missing 1 reference, evidence of relevant qualifications, full employment history, a pre-employment health check and evidence of their competencies. This file also contained the incorrect Disclosure Barring Service (DBS) check certificate, and the right one was immediately identified and replaced the incorrect one. Following the onsite visit, we were sent evidence of their prescribing qualification and a copy of their CV from 2024. This meant the service could not evidence safe recruitment at the point of recruitment.

From the sample of staff files we viewed, we found evidence 1 member of staff had received an annual appraisal in the last 12 months, and another was not yet due an appraisal as they were a newer member of staff. The final staff file we viewed contained an appraisal from 2024, but it was not signed or dated to confirm this.

We viewed monthly supervision notes for the non-medical prescriber but did not see evidence they were audited quarterly to make sure safe practices on independent prescribing were adhered to in line with policy.

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’s infection prevention and control (IPC) lead conducted regular risk assessments and audits to ensure compliance and took action where necessary to mitigate any identified risks.

Staff had completed relevant training in IPC.

The service had cleaning schedules available to staff, which outlined how to clean the building and its equipment. Cleaners completed cleaning schedules detailing daily and weekly tasks they completed. There was a communication book to liaise with the cleaners. Individual staff members were responsible for carrying out daily cleaning checks for the room they were using and recording these checks online. We viewed a sample of these records and found gaps in these. Although we did not find any cleanliness issues during the onsite visit, the service could not demonstrate how these were monitored for completion to maintain oversight of cleaning arrangements. Following our onsite visit, the service took action to address our concerns.

During our onsite visit, the service's premises and a sample of equipment reviewed was noted to be visibly clean. However, we found clinical waste storage bins outside were locked but were not stored securely. We also found a room containing the sluice (facility to safely and efficiently manage human waste such as urine samples) was left unlocked and the door open on several occasions. The door had a sign saying it should be kept locked. Following our onsite visit, the service took action to address our concerns.

We reviewed 3 staff files and found none of them contained evidence of all routine immunisations and selected (if required) vaccines in line with national guidance. Following the onsite visit, the service took action to address our concerns by reviewing what immunisations staff needed and would start requesting evidence.

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