Wychwood 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 found systems were in place to ensure appropriate use of medicines and to ensure risks associated with infection, abuse and use of premises and equipment were operated effectively.

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 service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff felt supported to raise concerns and that leaders treated them with compassion and understanding if they had a concern. Staff felt there was an open culture, and that safety was a top priority. The provider had processes for staff to report incidents, near misses and safety events and these were discussed.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

There were systems in place for processing information relating to new patients. The service worked with other providers to deliver shared care and when patients moved between services. We saw evidence that suggested referrals and test results were managed in a timely way.

The service worked with people and healthcare partners to ensure patient safety and the best way to achieve that based on people’s individual needs. They concentrated on improving people’s lives while protecting their right to live in safety, free from abuse, discrimination and neglect.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations. The inspection identified and prompted action for the provider to improve the level of alerting for staff on the clinical record system, for patients deemed potentially at risk.

Staff knew who the safeguarding lead was and felt able to report any concerns to them.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Emergency equipment was available and maintained. Staff could recognise a deteriorating patient and knew of action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

All staff were trained in basic life support. Reception staff had undertaken sepsis awareness training.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Contracts were in place to ensure the premises were maintained. Health and safety risk inspections and audits had been undertaken and risks identified had been addressed. There was a business continuity plan in place which was monitored and reviewed.

There were policies and procedures in place for the management of health and safety. A fire risk assessment was undertaken in 2024 and actions to ensure any risks identified were mitigated had been completed. Systems were in place for the regular checks of fire alarms, extinguishers and fire evacuation procedures.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development.

All newly employed staff had completed an induction to ensure they were competent in carrying out their role. Staff background checks were undertaken on staff to ensure they were safe and fit to work with patients. This included Disclosure and Barring Checks (DBS) (background checks to ensure people are not barred from working in certain roles).

The service assessed and managed the risk of infection. They detected and controlled the risk of healthcare related infections, with appropriate agencies where necessary.

We found that all staff had had completed their infection prevention control (IPC) training. The practice had a designated IPC lead, and they informed us they received appropriate advanced training.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

The practice had robust recall processes in place, to ensure patients were prompted when they needed a medicine review. A variety of communication methods were used to engage with patients, including text messaging, letters and telephone calls.

Staff received regular training, were competency assessed on medicines optimisation, and felt confident managing the storage, administration and recording of medicines.

We found that PGD’s (Patient Group Directions) were completed appropriately to authorise staff to administer vaccinations. These are agreed guidelines for non-prescribing clinical staff to administer certain medicines.

The practice had a dispensary and was able to dispense medicines to a proportion of its patients. We looked at the processes and systems to ensure patients received their medicines safely and that medicines were stored safely. We found that medicines were kept securely. Staff had the appropriate training to dispense medicines and process prescriptions. Checks were in place to ensure prescriptions were authorised prior to dispensing to patients.

Staff received regular training, were competency assessed on medicines optimisation, and felt confident managing the storage, administration and recording of medicines.

We undertook virtual searches on the provider’s clinical records system. This identified the majority of patients received their medicines safely and were prompted to undergo necessary checks in order to continue to receive their medicines safely. Where patients did not attend for necessary checks, such as blood tests, appropriate restrictions were put on their prescribed medicines to reduce the risk to those patients and prompt them to attend for the necessary monitoring.

Medicines, including vaccinations, were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines. The provider had effective systems to manage and respond to safety alerts and medicine recalls.