Mortimer 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

Staff kept facilities clean and maintained equipment appropriately to ensure people were kept safe. There were enough staff with the right skills, qualifications and experience. However, improvements were required to training and recruitment records to ensure checks were consistently completed and recorded.

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 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 all risks. The service had a business continuity plan which was regularly reviewed and outlined how the service should continue to operate in the event of a disruption.

Fire risk assessments had been completed and there were systems in place for the regular checks of fire alarms and extinguishers around the practice. The provider had appropriately stored all Control of Substances Hazardous to Health (COSSH) risk assessments for all cleaning products stocked.

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.

The service employed a range of clinical and non-clinical roles, which included GPs, nurses and paramedics. Leaders ensured staff were up to date with their training which the service had deemed mandatory and operated within their agreed areas of competence. The service followed safe recruitment procedures when employing staff, which were in line with national legislation. This included identity checks, obtaining of professional references and a criminal records check. We noted the recruitment checks were completed prior to staff commencing employment, and mandatory training compliance was consistently monitored. However, we found not all staff training was indicated as completed and some recruitment records were incomplete. For example, we could not obtain evidence to confirm that some staff had completed their mandatory Sepsis and Mental Capacity Act training. Information demonstrating this training had been completed by all staff was shared by the provider following the onsite visit.

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 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.

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. Staff had completed relevant training in infection prevention and control.

We noted the staff immunisation records were not fully up to date however these were promptly addressed by the provider following the onsite inspection.

We noted few clinical rooms were carpeted, however enhanced cleaning procedures were in place to mitigate risk, and the provider had plans in place to replace the flooring in the near future.

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