Moulton 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. As part of our assessment, we reviewed the practice’s policies, spoke with staff via video calls, and carried out on-site observations. With the provider’s consent and in line with data protection requirements, we also conducted remote clinical searches of the patient records system. We reviewed patient records to identify any concerns and confirm the actions taken by the provider. The practice had clear systems and policies in place for recording and responding to significant events and complaints and these supported compliance with the duty of candour. Learning from events was shared and used to improve the practice. There were also effective systems for the safe and appropriate use of medicines, including medicines optimisation.

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.

The practice promoted an open and transparent culture where concerns raised by both staff and patients were welcomed and seen as valuable opportunities for learning and improvement. Patients felt supported when raising concerns and reported that staff responded with empathy and compassion. Staff were proactive in addressing patients’ concerns, including non-clinical issues, aiming to enhance the overall patient experience. There was a clear focus on making a positive difference to each patient’s day and resolving issues promptly.

Minutes from Patient Participation Group (PPG) meetings showed that members felt the provider was responsive to feedback and took concerns seriously, resulting in meaningful service improvements. Managers fostered a culture of openness, where staff felt empowered to speak up when issues occurred. Incidents and complaints were thoroughly reviewed, with learning used to implement changes that enhanced the quality of care. Staff meetings were held regularly, creating space for reflection,shared learning, and team collaboration. The provider adopted a proactive approach to incident review at all levels, and key learning was often shared across the wider Primary Care Network (PCN) or Integrated Care Board (ICB) to support continuous improvement within the local health system. Staff consistently described a culture of openness, underpinned by a strong focus on safety. Clear systems were in place for reporting incidents, near misses, and learning events. When errors occurred, staff were open, offered apologies, and provided support to those affected.

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.

The service worked with other providers to deliver shared care and when patients moved between services. Referrals and test results were managed promptly, and a dedicated team of administrative staff was in place to support patients in safely transitioning between services. Systems for managing information related to new patients were current and effectively maintained. The practice worked collaboratively with other providers to ensure continuity of care, particularly when patients were receiving shared care or moving between services. Correspondence was handled promptly, reviewed by appropriate staff, and acted upon to maintain safe and effective care. Clear processes ensured that referrals and test results were managed without delay. For urgent referrals, a tracking and auditing system had been introduced, allowing the administration team to monitor progress and ensuring that the referring clinician reviewed the outcome and provided appropriate follow-up for the patient.

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

Safeguarding policies were in place and clearly understood by staff, all of whom had received training appropriate to their roles. The practice maintained an up-to-date register of vulnerable patients and worked closely with external agencies to respond to concerns. The safeguarding lead regularly reviewed cases and relevant information was shared within the team to ensure coordinated and effective care. There was a strong focus on protecting individuals' rights to live safely and free from abuse, discrimination, avoidable harm, and neglect. Concerns were shared promptly and appropriately with partner organisations. Staff were confident in recognising and reporting safeguarding issues and knew how to access the safeguarding lead when needed. They were familiar with the systems and processes in place to keep people safe. The practice had robust procedures that reflected close partnership working with local safeguarding teams and other relevant agencies. Electronic alerts on patient records helped clinical staff identify potential safeguarding risks. Regular meetings were held with professionals such as social workers to ensure the safety and well being of vulnerable adults and children.

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.

A clear system was in place to ensure all staff understood their roles during a medical emergency, enabling an effective and coordinated response. Any such incidents were recorded as learning events, with reports completed promptly and added to the patient’s record. Staff were trained to identify signs of deterioration and were confident in taking appropriate action. A duty doctor was available each day to provide support for patients requiring urgent attention and emergency equipment was available and maintained. Staff were also trained to recognise symptoms that may indicate the need for immediate medical intervention.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

There was a business continuity plan in place which was monitored and reviewed. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments. Staff understood their responsibilities in maintaining a safe environment and knew how to respond in emergency situations. They had completed relevant training, including health and safety, fire safety, and information governance. The premises and facilities were suitable for the services provided, and equipment was well maintained and fit for use. Environmental risks had been assessed, and necessary actions were taken to mitigate them.

Clear signage throughout the building supported safe evacuation, and fire evacuation grab packs were strategically placed. The practice had made reasonable adjustments to support individuals who found it difficult to access services and was responsive to the needs of people in vulnerable situations. Health and safety risk assessments had been carried out thoroughly, with evidence of safe systems and processes in place to promote a secure environment.

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 practice employed a diverse team of clinical and non-clinical staff who worked collaboratively to support patient care. There were effective systems in place to ensure that staff training was kept up to date, with ongoing management of learning needs and professional development. Staff were encouraged and supported to develop new skills and undertake additional training to enhance their abilities and career progression. Many staff members had long-standing employment with the practice, with some advancing to more senior positions through internal support. A strong process was in place to ensure staff worked within their defined competencies. The practice regularly conducted audits of patient-facing roles to ensure accurate documentation, prescribing, and treatment planning. Results were clearly recorded, and any learning outcomes were shared within the team to improve overall knowledge. Non-clinical staff, including administrative staff had regular appraisals and recruitment procedures were thorough.

The service thoroughly assessed and managed the risk of infection. They always quickly detected and controlled the risk of it spreading and always shared concerns with appropriate agencies promptly.

The practice had a designated lead for infection prevention and control, and all staff had received appropriate training. Cleaning schedules were established and adhered to consistently. Risk assessments and audits were regularly conducted, with prompt actions taken to address identified risks. Staff were aware of the infection control lead and actively contributed to ensuring compliance with all relevant policies and procedures. Clinical rooms were adequately stocked with personal protective equipment (PPE) and hand washing facilities. Hand hygiene audits were completed annually, and following our onsite visit, infection prevention and control audit reports were provided, showing that necessary corrective measures had been implemented. Waste management processes, including the safe handling of sharps and clinical specimens, were appropriately managed to maintain safety.

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.

Clinical searches carried out were found to be safe. Our review found no evidence of any missed diagnoses for patients and there were clear systems in place for patients on prescribed medicines which require monitoring. Patients were informed about what actions to take if their condition worsened or if they experienced unexpected symptoms. Staff took care to prescribe medicines responsibly to optimise treatment outcomes, including the use of antibiotics. The number of antimicrobial prescribed by the practice was lower than both local and national averages. The practice also monitored patients who frequently requested medicines to ensure their treatments remained appropriate. Medicines were stored securely and maintained at appropriate temperatures. The practice provided patients with guidance on correct home storage of medicines where required. Regular stock checks were carried out for all medicines, including emergency supplies and vaccines, with attention to expiry dates. The provider had effective systems to manage safety alerts and medicine recalls promptly.