Capelfield 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 avoidable harm. At our last assessment, we rated this key question as good. At this assessment, the rating remains the same.

This service scored 72 (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 to detect and control potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. These had operated consistently in all areas we sampled except 1 which was the system to manage the risk of infection from Legionella (a type of bacteria found in water systems).

The service had received the most recent Legionella risk assessment the day before our visit and the risk had increased from medium to high. The service was accepting of the findings and was working with the external contractor who assessed the premises to create an action plan to manage the risk while remedial action was taken to reduce the risk as quickly as possible. The service had placed this risk on their own risk register and were monitoring the situation weekly which gave assurance the service was responding appropriately to ensure the safety of people using the service.

Staff and leaders completed health and safety risk assessments and had systems which provided oversight of risks and ongoing actions to manage the premises. Fire safety equipment was maintained, and we found fire drills took place.

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.

The systems to ensure staff were recruited safely did not always follow national legislation and processes to obtain staff’s vaccination status had not always operated as intended. The service employed enough qualified, skilled and experienced staff and made sure staff received effective support, supervision and development. Staff 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, paramedics and pharmacists.

Leaders ensured staff were up to date with training which the service had deemed mandatory and operated within their agreed areas of competence. We sampled training records for 3 members of staff and all were up to date according to the service’s policy. We found a decision had been made in August 2025 to remove 2 training courses from the mandatory training requirements which were infection, prevention and control and recognising the deteriorating patient. The registered manager explained the reason was because of the time necessary to complete the significant number of training courses required and on review the registered provider had been felt these areas were covered in team meetings and other courses. Leaders reviewed this decision on the day of our visit and reinstated the courses on the mandatory list but because of reinstating them, 5 members of staff needed to complete training. The service made an action plan for this to be completed by 31 May 2026.

The service had recruitment procedures when employing staff but these had not always followed national legislation. For example, our sampling did not find evidence that the professional registrations of 2 members of clinical staff had been confirmed when they were employed. The service policy was to check this at the point of recruitment and monitor thereafter but this system had not always been followed. Checks were completed and those staff records were updated immediately.

We also found the service did not hold full employment histories for 2 members of staff so the reasons for gaps in their employment history were not recorded. Leaders explained the reasons were known and for 1 member of staff the service found they held a curriculum vitae (CV), but it had not been added the to the file and for the other member of staff a declaration to confirm the reasons was signed and added on the day.

We found identity checks, reviews of qualifications, obtaining of professional references and a criminal records check had been completed.

The service’s immunisation policy for staff followed national guidance, although the system to monitor staff’s status had not operated consistently because our sampling found incomplete records for all 3 staff sampled. One file did not have a complete record of vaccinations but the information was added on the day of our visit. Another file was missing information for 1 vaccination but the service was confident the staff member had been vaccinated because of action taken to review this previously. It was confirmed during our visit that the information was recorded in another system and the staff record was updated. For the third member of staff, their vaccination declaration had been completed but not signed off by a GP partner as per the service’s policy. This was actioned on the day of our visit.

Staff received appraisals and had access to supervision.

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.

Staff had completed relevant training in infection prevention and control, however, as a result of the previous decision not to require repeat formal training, 1 member of staff was overdue, and the provider had an action plan in place to address this promptly.

We found, 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.

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