Church View 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 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.

Staff and leaders completed health and safety risk assessments and undertook audits to ensure they had identified and addressed all risks. For example, daily, weekly and monthly checks of the premises.

The service had an up to date fire risk assessment. Staff conducted weekly fire tests, were trained in fire safety and there were trained fire marshals.

The service held contracts to ensure the premises was maintained. For example, gas and electrical equipment had annual servicing and medical equipment was calibrated in line with manufacturers recommendations. Safety alerts relating to equipment were shared with the relevant staff and acted on. Portable appliances were tested on an annual basis. Records we viewed showed the service completed maintenance checks in line with requirements.

The service had a business continuity plan which leaders reviewed regularly and outlined how the service should continue to operate in the event of a disruption.

The service was accessible for all people and included space for wheelchairs and prams. Hallways and corridors were clean and tidy and free from clutter. Staff offices were secure, and access was restricted from the public.

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 dispensary staff.

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.

Staff worked within their agreed areas of competence. Staff told us their development and support were a priority to management, and staff had developed into additional roles including lead roles. Staff were encouraged to access additional training they felt would support their development. All staff had annual appraisals that focussed on development and staff wellbeing. However, we found that not all staff were up to date with training which the service had deemed mandatory. For example, safeguarding refresher training, moving and handling and information governance. Following our site visit, the service provided evidence to show this had been completed. Where gaps remained due to staff absences, the service had implemented an action plan to ensure completion upon their return.

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.

We saw the infection prevention and control lead had undertaken a specific 2 day infection and prevention control course to support them to carry out their role. Staff had completed relevant training in infection prevention and control.

The service’s infection prevention and control (IPC) lead conducted regular risk assessments and audits to ensure compliance and acted where necessary to mitigate any identified risks.

Clinical rooms had adequate provision of personal protective equipment (PPE) and handwashing facilities. Audits were undertaken on hand hygiene on a regular basis, to make sure staff used effective techniques to maintain hand cleanliness.

The service held records of staff immunisations, to ensure staff and people using the service were protected against infectious diseases.

During our visit, the service's premises and a sample of equipment reviewed was noted to be visibly clean. The service had cleaning protocols available, which outlined how staff should clean the building and its equipment. Cleaners maintained records of daily and weekly tasks they completed, these were reviewed by the service. A communication book was used so that the service could inform cleaners of any concerns, and the cleaners were able to respond to these. The service carried out monthly audits of cleaning arrangements and undertook joint audits with the cleaning company on a quarterly basis to monitor standards of cleaning. The service took action to mitigate any identified risks.

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