Brig Royd 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 75 (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.

Contracts were in place to ensure the premises was safe and well maintained. Staff and leaders completed health and safety risk assessments and undertook audits to ensure they had identified and addressed risks. We saw all checks such as gas safety, portable appliances testing and calibrations were up to date. In addition, we saw evidence of regular fire alarm tests, fire extinguisher maintenance and fire risk assessments had been completed.

The premises was clean and in a good condition. There was a business continuity plan in place which was monitored and reviewed.

The service had considered the needs of children and families. The waiting area included a designated space for children.

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.

Staff recruitment procedures were in place to ensure staff were appropriate to work in the service. This included identity checks, review of qualifications, obtaining of professional references and a criminal record check. Leaders told us staff were provided with protected time to complete mandatory training. However, we found gaps in training records which the practice manager had identified and recognised and had put an action plan in place to address them.

The practice employed a range of clinical and non-clinical team members, including GPs, advanced nurse practitioners, nurses and health care assistants. In addition, the practice had expanded its workforce through the inclusion of Additional Roles Reimbursement Scheme (ARRS) roles, which increased capacity and improved patient access to appropriate care and treatment.

Clinical supervision arrangements were in place. Formal records of routine supervision were not consistently documented. However, leaders told us they did not usually record supervision discussions unless significant concerns were identified. Where performance concerns were raised about a clinician, these would be documented on the service's system and managed through an appropriate action plan.

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 service had effective systems in place to manage infection prevention and control (IPC). A dedicated IPC lead was in place and had received formal training. All staff completed IPC training annually. An annual IPC audit, monthly hand hygiene and personal protective equipment (PPE) compliance audits had been undertaken by the IPC lead. At the time of our assessment no IPC actions had been identified. We found the service premises and equipment to be clean and tidy. Appropriate PPE was available to staff.

Staff immunisation status was recorded, and where evidence was unavailable, blood tests had been undertaken. Handwashing posters were clearly displayed, and used sharps were stored safely with appropriate labelling completed.

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