Shoreditch Park 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 staff protected people from avoidable harm and made sure care was delivered from environments that were clean and well maintained. 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.

The practice premises were clean, well-maintained and suitable for service delivery. Staff could report risks and issues to the external landlord responsible for premises maintenance and monitor and escalate repairs through an online system. However, there was no effective oversight to monitor risks or ensure completion of identified actions. The frequency of portable appliance testing was also not supported by a documented risk assessment.

Relevant health and safety assessments were completed, including fire, electrical and water safety checks and leaders were taking action to strengthen oversight of systems and processes to ensure safety.

Fire alarms, emergency lighting, fire doors and firefighting equipment were regularly tested, and fire drills were recorded. Clinical rooms, medicines, hazardous substances and restricted areas were securely stored or access controlled.

Equipment was serviced, calibrated and safety tested, and emergency medicines and equipment were checked regularly. Safety alerts were reviewed and acted on, and the practice maintained a current business continuity plan that was reviewed following incidents or organisational changes.

The service had enough staff, and staff worked well together to meet people's needs. However, the service could not always demonstrate through its records that recruitment, training and supervision requirements had been met.

Named general practitioners provided daily cover, with a partner available for clinical advice, and nursing staff worked within their assessed competencies, with clinician support available.

We reviewed 5 staff files and found recruitment checks were not always complete or consistently recorded. None contained a health declaration, 2 lacked a complete employment history, 2 lacked evidence of qualifications, 2 lacked evidence of current professional registration, and 1 lacked right-to-work documentation. Appropriate Disclosure and Barring Service checks were in place for all 5 staff.

The practice did not have a formal recruitment policy and did not retain written assurance that pre-employment checks had been completed for Primary Care Network staff working at the practice. Locum GPs were sourced through a platform that verified mandatory checks before placement.

Formal supervision arrangements for nursing staff were not embedded before the assessment. A protocol was introduced the day before our visit, but no previous supervision records were available. One nurse's appraisal status could not be confirmed and no documentation available. Appraisal records were otherwise incomplete, and administrative staff appraisals had lapsed. There was no documented process for escalating performance concerns from informal conversation to formal management action. GPs completed annual appraisal and revalidation.

At the time of the assessment, the practice had not defined role-specific mandatory training requirements or renewal frequencies, and staff could not confirm which courses individual staff were enrolled in. A training matrix subsequently provided showed gaps for 6 of 21 staff in areas including basic life support, fire safety, infection prevention and control, the Mental Capacity Act, safeguarding and information governance.

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.

The practice had effective arrangements to assess and manage infection risks. It worked with the local NHS infection prevention and control team, and actions from external inspections were monitored through a digital platform.

An Infection prevention and Control policy was in place, and hand hygiene audits had been completed. Clinical areas and equipment were visibly clean, uncluttered and well maintained.

Staff had completed relevant training and understood procedures for managing infectious patients, clinical specimens, sharps and waste.

Appropriate handwashing facilities, personal protective equipment and clinical waste arrangements were appropriate.

Staff vaccination records were maintained, and there was a clear process for reporting notifiable diseases.

IPC was regularly discussed at clinical meetings.

However, there was no single formally designated IPC lead at the start of our assessment and staff told us this responsibility was shared between two practice nurses. Following our assessment, the practice provided an updated relevant policy, which continued to describe the infection prevention and control leadership as shared between two named nurses rather than a single designated lead, and the practice's own infection control inspection checklist, used to audit this question, had not been completed. Room-cleaning schedules and consumables checklists were not available for review at the time of our assessment and were provided by the practice in the days following our visit.

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