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

Appropriate premises maintenance schedules were in place, recent maintenance documentation was reviewed, including the Electrical Installation Condition Report, gas safety certification, and records relating to fire alarms, fire extinguishers, and emergency lighting. Any actions highlighted had been completed within a reasonable time frame.

Risk assessments were in place for fire safety, Control of Substances Hazardous to Health (COSHH), and health and safety. However, at the Garforth site, the legionella risk assessment was out of date. This had been identified by the service in preparation for the CQC assessment, and arrangements had been made for this to be carried out, with interim control measures being put in place. The fire risk assessment had been completed internally; this was currently being reviewed by a suitably qualified external provider.

Fire evacuation drills and routine fire alarm testing were undertaken, an accident book was available, and health and safety posters were displayed.

The service made sure there were enough qualified, skilled and experienced staff who worked together to provide safe care that met people’s needs. Rotas were planned to ensure there was an appropriate skill mix across both sites.

The service employed a range of clinical and non-clinical staff and had recruitment and onboarding procedures in place. Disclosure and Barring Service (DBS) checks were completed prior to staff commencing employment. Inductions were carried out for all staff and included both role-specific and practice-specific elements, such as fire safety training and shadowing opportunities. Administrative staff undertook a structured induction programme which included competency checks, in-depth training, and regular meetings with their team leader. However, when we reviewed staff records, we found some gaps in recruitment documentation, including missing CVs and a lack of retained interview notes. The service had identified this prior to the assessment and had plans in place to ensure interview records were retained going forward. Some staff contracts were not signed at the time of inspection, but signed copies were provided following the visit.

Clinical supervision was established, with evidence of sessions being recorded and documented. The service also maintained a comprehensive locum pack, and processes were in place to verify locum staff credentials. Professional registration checks were carried out annually.

Staff were supported in completing mandatory training and given protected time to do so. However, appraisal processes were not consistently implemented, with some staff, including members of the nursing team and managers, not having received an appraisal within the previous year. Following the onsite visit, the service booked these appraisals in.
 

The service had systems in place to assess and manage the risk of infection prevention and control (IPC). An IPC lead was in place and had received appropriate training for the role. All staff completed IPC training annually, and an IPC audit had been undertaken in June 2026, with oversight by the IPC lead.

The premises were mostly clean and well maintained, although we observed some areas where improvements were required. Cleaning arrangements were in place at both sites, with contracted cleaners using colour-coded equipment stored in dedicated areas. At the time of inspection, there were no cleaning checklists in place to evidence what had been completed; the service provided evidence following the inspection that these had been introduced.

Additional IPC monitoring processes were not fully embedded. For example, hand hygiene audits had not been completed; however, these had been incorporated into a newly updated IPC policy. Staff immunisation records were maintained, and where vaccinations were declined or contraindicated, this was documented appropriately.

Handwashing guidance and sharps injury procedures were clearly displayed. Used sharps were managed and disposed of safely, with appropriate labelling. Some non‑wipeable chairs were in use within clinical areas; the practice advised that leaders had arrangements in place to meet and implement a plan for the phased replacement of all non‑wipeable chairs.

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