The Dovecot 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 that 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.

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.

People felt supported to raise concerns and reported that staff treated them with compassion and understanding. Managers promoted a culture of openness and encouraged staff to speak up when things went wrong. Clinical issues were discussed as a team during staff meetings, creating opportunities for shared learning.

The provider maintained a structured process for recording and investigating incidents and complaints. When things went wrong, staff apologised and supported those affected. They discussed learning from incidents in team meetings and implemented changes to improve care. For example, following an emergency incident at the practice, a review of the equipment ordering processes was carried out. As a result, a more effective system was introduced to ensure all emergency equipment was properly accounted for and replenished promptly.

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.

Systems were in place for processing information relating to new patients, managing test results, and coordinating referrals. The service worked in partnership with other providers to deliver shared care and manage transitions between services.

Referrals to specialists and urgent services, including 2-week-wait (2WW) referrals, were managed through a clear process. Once a 2WW referral template was completed, it was automatically sent to the administrative team and marked as pending in the clinical system’s referral task group until an appointment was confirmed. If no appointment was visible, the administrative team contacted the hospital directly to ensure the referral had not been overlooked. This system provided timely follow-up and oversight, with the administrative team responsible for monitoring and managing referrals to ensure patients were seen within appropriate timeframes.

The practice had systems in place to identify and respond to safeguarding concerns. Although regular safeguarding meetings were not yet established to provide structured oversight, individual concerns were addressed appropriately, and there was evidence that these were shared with relevant partners when required.

The provider’s safeguarding policies for adults and children listed the wrong safeguarding lead. We raised this with the provider, and we saw they promptly amended the policies.

Most staff had completed safeguarding training appropriate to their role. Staff were clear on who the safeguarding lead was and reported they could access support when needed.

The practice had a chaperone policy in place to provide reassurance and mitigate risk for both patients and staff. Disclosure and Barring Service (DBS) checks were undertaken when required.

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.

Most staff had completed their Basic Life Support (BLS) training. Those who had not yet completed it had been booked onto upcoming sessions.

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 practice operated from a rented building, with maintenance and cleaning services provided by the building owners. Contracts were in place to ensure these services were delivered consistently, supporting the upkeep and safety of the premises.

Health and safety risk assessments and audits, including a Legionella risk assessment, had been undertaken, with identified risks appropriately addressed. A business continuity plan was in place and subject to regular monitoring and review.

The environment was secure, featuring fob-controlled access, secure storage facilities and a visitor sign-in protocol.

The service had enough qualified and skilled staff to deliver safe care that met people’s needs. Staff worked well together and received support through appraisals and ongoing training. Some areas for improvement were identified, including the absence of a formal process for assessing clinical competence. This process was introduced at the time of the assessment and was not yet fully embedded in the practice.

A nurse prescriber worked at the practice 1 day a week. Their clinical competencies were assessed by another provider that also employed them, and the practice had oversight of their work but had not yet carried out its own formal competency assessment. Plans were in place to introduce this process as part of internal governance.

Clinical competencies of nurse consultations took place on an ad-hoc basis and were not routinely documented. The practice recognised this and recently formalised the process by implementing a documented 6-monthly review of nurse consultations to provide oversight and assurance. In addition, support was available through daily scheduled clinical time, attended by GPs, registrars, nurses, and healthcare assistants (HCAs). This provided an opportunity for informal debriefs and discussion of cases seen during previous clinics.

There were a range of clinical and non-clinical roles within the practice. We found learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence. Safe recruitment practices were followed. Gaps in mandatory training were identified during the assessment. These were raised at the time, and leaders assured us they would be addressed promptly. After the site visit, the provider told us most of the training had been completed, with a deadline set for resolving the remaining gaps.

While new processes, including formal clinical competency assessments, had been introduced and improvements were evident, further work was needed to ensure these systems were consistently and effectively embedded.

The service did not always assess or manage the risk of infection effectively. There was not an effective process in place to assure that all staff (clinical and non-clinical) were protected from infection through appropriate routine pre-exposure immunisation. This was not in line with guidance issued by the UK Health Security Agency, as outlined in the Green Book: Immunisation Against Infectious Diseases.

Following the assessment, leaders acted promptly by offering vaccinations, completing risk assessments for unvaccinated staff, and updating staff records to reflect current immunisation status.

The practice had a designated infection, prevention and control lead and all staff had received relevant training. Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks.

Cleaning arrangements were provided by a third-party contractor. These services were managed by the landlord.

The service had systems to ensure medicines were managed safely and met people’s needs; however, some improvements were required.

Monitoring of high-risk medicines was not always in line with national guidance. For example, a small number of patients prescribed Direct Oral Anticoagulants (DOACs) had not received the recommended level of monitoring. Medicines reviews for patients with long-term conditions were sometimes delayed or lacked clinical detail. The provider took action to improve review processes, raise staff awareness, and strengthen oversight to ensure future compliance.

Risk documentation and pregnancy prevention forms were initially missing for a small number of patients prescribed medicines that can cause harm in pregnancy (teratogenic medicines). On review, the provider found that some forms had already been completed but were filed under ‘Miscellaneous’ on the clinical system. Staff subsequently completed all remaining forms, ensuring appropriate documentation was in place.

Follow-up of raised HbA1c levels, a blood test that shows average blood sugar levels, was not always in line with national guidance for prediabetes management. A review confirmed that appropriate lifestyle advice and monitoring had been offered, and processes have now been strengthened to ensure timely follow-up and accurate clinical coding.

An isolated incident was identified involving the handling of prescription stationery, where FP10 prescription forms had been left unattended. This was reviewed and confirmed to be a one-off occurrence. The provider reinforced prescription handling protocols with all staff.

At the time of assessment, some emergency medicines were not stocked, and risk assessments were not in place to record the rationale for this. Additionally, emergency medicines and resuscitation equipment were temporarily inaccessible due to a locked door. These issues were immediately addressed, with risk assessments completed, and staff reminded of procedures to ensure emergency items always remained accessible.

Medicines were stored, administered, and documented appropriately. Staff regularly checked medicines, including vaccines and emergency drugs, for stock levels and expiry dates. Medical gases were stored safely, and staff held appropriate authorisations under Patient Group Directions (PGDs).

The provider introduced new processes to strengthen medicines management, including monthly safety-net searches and a new “birthday month” review system to help ensure timely and consistent reviews. While improvements were evident across several areas, further work was required to ensure these systems operate consistently and effectively.

The practice was also recognised by the Integrated Care Board (ICB) for significantly improving prescribing safety, achieving a 31% reduction in Short-Acting Beta-Agonist (SABA) inhaler prescribing over 12 months. This placed them as the 9th highest SABA-reducing practice across the entire ICB.