Colliers Wood 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 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.

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. Weekly clinical governance meetings were held. During these meetings, the whole team discussed and learnt from clinical issues.

Staff we spoke with told us they 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. Leaders told us there had been 10 significant events in the past 12 months. We discussed 2 of them and they had been handled in line with their policy.

There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. 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. This included having a dedicated member of staff who was responsible for summarising new patients notes.

The service worked with other providers to deliver shared care and when patients moved between services. For example, ensuring smooth transition of information when a child reached 18 and needed to be moved to an adult service or patients discharged from hospital.

Referrals and test results were managed in a timely way. Staff told us that urgent results were processed on the same day. They had an automatic system that filed routine results which was managed by two members of staff. To ensure results were not delayed or missed, they were triaged to another GP if the referring GP was away.

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

Safeguarding policies were in place and known to staff. There were separate policies for children and adults, and the lead and deputy leads were named in both policies. All staff who we received feedback from were aware of who the leads were.

Managers told us they had a proactive approach to safeguarding and ensured all staff had been appropriately trained in safeguarding procedures. The standard level of training was set at level 3 for both children and adults for clinical and non-clinical staff. Other ways of monitoring vulnerable children were through nurses monitoring children’s failed attendance records.

The practice maintained a robust list of vulnerable people and acted on concerns working in partnership with other organisations. For example, they had a professional contact document outlining all relevant Merton organisations such as Designated Doctors and Medical advisors, Fostering and Adoption agencies, the Southwest London safeguarding contacts and local advocacy organisations.

We saw evidence of how they met regularly and shared information appropriately with other services such as health and social care professionals, health visitors and social workers. Minutes of meetings with professionals such as health visitors demonstrated their joint working. Minutes of a meeting demonstrated that they were consistently looking for way to improve inter-agency collaboration. Safeguarding was also discussed internally, and we saw evidence of this in clinical governance meeting minutes.

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. Equipment and medicines were stored in a central place which was accessible to all staff. Appropriate checks were completed to equipment on a weekly basis. Staff we spoke with were aware of what to do in an emergency and demonstrated they knew how to use equipment. Improvements were required to ensure emergency medicines were stored securely. We discussed this with the practice manager, and they assured us this would be resolved. Doctors carried out home visits and they had “Doctors bags” which had the appropriate medicines and were checked regularly.

Staff could recognise a deteriorating patient and knew of action to take. For example, all staff had completed sepsis training and knew how to triage a patient if they presented with symptoms. 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. The practice used an external company to carry out their fire, legionella and general health and safety risk assessments. These were completed on an annual basis. We reviewed the risk assessments completed for 2025 and saw that all recommended actions suggested had been completed. At the time of the inspection there were a few building maintenance issues that needed attention. One related to an internal door that needed repairing to make that area of the practice more secure. The provider assured us that this and the other repairs were in the process of being completed.

There was a business continuity plan in place which was monitored and reviewed.

The service had qualified, skilled and experienced staff. However, staffing rotas indicated that improvements were required to fulfil the demands of the service at particular times. Most staff received effective support, supervision and development. The staff team worked together to provide safe care that met people’s individual needs.

There were a range of clinical and non-clinical roles within the practice. Patient feedback indicated that they felt there were challenges in getting appointments at the practice. We reviewed the appointments availability for a specific period over the past month. We identified that fewer appointments were available than had been scheduled to be available. Some of this was due to the way staff annual leave was arranged, with clinicians being absent over the same period. We discussed this with the managers and agreed that whilst staff absence was unavoidable in some cases, better planning could help in maximising appointment availability.

We found training was up to date, learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence.

Safe recruitment practices were generally followed. We reviewed 5 staff records and saw that full employment history was not always collected, 2 references were not present in all of the staff records that we reviewed (the provider’s policy stated that 2references were obtained) and job descriptions were not up to date for all files we reviewed.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate.

The practice had a designated infection, prevention and control lead and all staff had had relevant training.

Cleaning schedules were in place and followed. The schedules outlined, daily, weekly and monthly cleaning routines. There was a contract in place with an external contractor who carried out the cleaning. No concerns were observed during our on-site visit. Schedules were also in place for cleaning rooms and equipment. Clinical staff were responsible for this and signed to confirm they had completed the required cleaning after using a room. There were appropriate supplies of personal protective equipment such as gloves and aprons.

Risk assessments and audits were completed, and actions taken to mitigate risks. We reviewed the last audit completed in September 2025. All actions identified had been completed or were in the process of being completed.

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. The computer system automatically reminded clinicians of patient review dates. Staff used this to help them monitor. Staff told us that patents were invited to be involved in their reviews.

People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms. Staff received regular training, were competency assessed on medicines optimisation, and felt confident managing the storage, administration and recording of medicines.

Staff managed prescription stationery appropriately and securely. Access was restricted to authorised staff only with a designated member of staff responsible for managing and overseeing storage. There was a robust process for logging serial numbers of prescription.

Staff followed protocols to ensure they prescribed all medicines safely, and ensured people received all recommended medicines reviews and monitoring.

Medicines including controlled drugs were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines, vaccines, and controlled drugs.

Waste medicines were recorded and disposed of appropriately including medicines returned by patients.

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.