Pilch Lane 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 service had contracts to ensure the premises was maintained. Staff and leaders completed health and safety risk assessments and undertook audits to identify and monitor risks within the environment. The service had a business continuity plan which was regularly reviewed and outlined how the service should continue to operate in the event of a disruption.

The practice had systems in place to support the safety of the premises, including fire safety arrangements, health and safety risk assessments, equipment calibration, servicing schedules and business continuity planning. Staff told us they felt safe within the practice environment and knew how to report concerns. The provider maintained records relating to fire safety, gas safety, security and health and safety risk assessments.

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

The service employed a range of clinical and non-clinical roles, which included GPs, nurses, and administration staff. Leaders ensured staff were up to date with their training which the service had deemed mandatory and operated within their agreed areas of competence. We reviewed some staff files and found that the service followed safe recruitment procedures when employing staff, which were in line with national legislation. This included identity checks, review of qualifications, obtaining of professional references and a criminal records check.

There were systems to support staff through induction, appraisal and mandatory training. Staff described access to online training, protected learning time and annual appraisal processes which included discussion of development needs. The practice maintained staffing levels through internal cover arrangements, and leaders told us they ensured sufficient numbers of staff were available to meet patient demand. We reviewed staff training records and found that staff were up to date with mandatory training.

The practice had systems and processes to support infection prevention and control. There was a designated infection prevention and control lead who was known to staff, and infection prevention and control formed part of staff induction and ongoing training arrangements. The provider completed regular infection prevention and control audits, including hand hygiene audits and monthly PPE audits, with recent infection prevention and control audits achieving full compliance scores. Staff had access to policies, procedures and guidance relating to infection prevention and control.

We observed that cleanliness within one clinical area was not of the standard expected and we observed damaged flooring within the same clinical room. The practice had previously used a portacabin for phlebotomy appointments which did not have functioning hand washing facilities. After the inspection the provider sent in further evidence to demonstrate that actions had been taken. The manager updated the cleaners schedule to ensure all areas of the clinical room were cleaned, PPE had been put into all clinical rooms, and the provider informed us that the portacabin was to be removed and was not currently in use.

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