Ballater 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 felt staff treated them with compassion and understanding.

Managers encouraged staff to raise concerns when things went wrong. During staff meetings, the whole team discussed and learnt from clinical issues. 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. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Staff reflections were built into the process for analysis of incidents. Learning from incidents and complaints resulted in changes that improved care for others.

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. Staff were aware of their responsibilities in relation to referrals. The practice had a robust process to ensure patients received their referral. Patients were followed up with to determine whether they had attended their appointment. Test results were managed in a timely way. There was a system in place to ensure urgent results were reviewed, including when the requesting clinician was on leave.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Safeguarding policies were in place and known to staff. The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations. There were flags on the practice’s system to alert practice staff to patients who may be in vulnerable circumstances, for example care leavers. We saw a number of examples where practice staff had acted in line with the practice policy to keep people safe.

We reviewed the training records of 5 staff members. We found 1 member of clinical staff had not completed safeguarding adults training. Another member of clinical staff had completed safeguarding children and adults training; however, this was not at the level required for their role. Following our site visit the provider showed us evidence this training had been completed.

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.

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 assessments and audits had been undertaken and risks identified had been addressed. There was a business continuity plan in place which was monitored and reviewed.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support and supervision They worked together well to provide safe care that met people’s individual needs.

There were a range of clinical and non-clinical roles within the practice. Safe recruitment practices were followed.

We found training was not always up to date. We found not all staff had completed training appropriate to their role, including basic life support, fire safety, infection control, safeguarding, and training to support autistic people and people with a learning disability. Staff told us they were not always given protected time to complete their training.

Following our inspection, the provider showed us evidence this training had been completed. The provider also told us they had recorded the identified lack of training as a significant event and had put measures in place to ensure appropriate oversight of staff training.

The service assessed the risk of infection and had identified some areas for improvement; however, we found that action hadn’t always been taken to resolve these issues. For example, the provider had carried out a legionella risk assessment in April 2026 which had found that water from some hot water outlets did not reach a temperature of 50°C or higher (hot water should be distributed at 50°C or higher to reduce the likelihood of legionella bacteria being able to multiply). The provider had identified that this required further investigation, including sending a water sample to a specialist company for analysis, however at the time of our inspection this had not been actioned.

We requested details of staff immunisations held by the practice. The provider told us this information was not routinely collected or reviewed for non-clinical staff. We reviewed the records for 3 clinical staff and found these records were incomplete.

Following our inspection, the provider told us they had updated their processes. This included collecting evidence of immunisations for all staff with direct contact with patients and completing risk assessments where this information was not available.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

Staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely. People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms.

Staff followed protocols to ensure they prescribed all medicines safely. We found a small number of patients were not up to date with recommended monitoring and reviews, however we saw the provider had taken action to resolve this, such as making multiple attempts to contact patients using different methods of communication, and by reducing the quantity of medicine prescribed.

Medicines were stored securely and at appropriate temperatures. We saw some instances of out-of-range refrigerator temperatures (these refrigerators contained medicines that should be stored between 2°C to 8°C). Whilst staff were aware of the provider’s processes regarding out-of-range temperatures, it was not clear that these processes were always followed. The provider used a data logger which measured temperature over time and review of the data provided by the data logger confirmed that medicines had not been stored at a high temperature for a length of time that would compromise quality or safety. Following our site visit, the provider told us that additional training had been arranged for staff in relation to the processes for monitoring medicines stored in a refrigerator.

Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines, vaccines, and controlled drugs. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments.

The provider had effective systems to manage and respond to safety alerts and medicine recalls. Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring. Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. Prescribing data reviewed as part of our assessment confirmed this. For example, the number of medicines to treat uncomplicated urinary tract infections issued by the provider was lower than local and national averages.

There was a programme of regular clinical audits of prescribing that focused on improving care and treatment