West Rainton 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.

This service scored 78 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Leaders embedded, maintained and sought to continuously improve a culture of openness and collaboration and safety was everyone’s top priority. The service had a strong proactive and positive culture of safety, based on openness and complete honesty. They actively listened to concerns about safety and thoroughly investigated and reported safety events. Lessons were always learnt to continually identify and embed good practice. We found there were systemic approaches to learning, which were well embedded and incorporated into every day working. This supported active learning, with integral involvement of staff.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. Representatives from the Patient Participation Group (PPG) felt the provider took concerns seriously and proactively made improvements to the service. There was strong feedback from the group that the practice acted upon their feedback and were resilient and tenacious in resolving issues to improve patient experience. For example, they had worked to reduce the number of patients who did not attend appointments. Data provided by the practice showed that in March 2025, that as well as the 3358 appointments attended, 171 patients failed to attend an appointment. This compared with 3282 appointments attended in September 2025, with 77 patients who failed to attend. This showed a significant reduction were continuing to advocate on behalf of patients to improve the safety of car parking arrangements.

We found leaders encouraged and rewarded staff for raising concerns about safety and ideas to improve, and the value of learning was continually demonstrated and reinforced by leaders. During staff meetings, the whole team discussed and learnt from clinical issues. Staff felt there was an open culture, and that safety was a top priority. The provider had processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Learning from incidents and complaints resulted in changes that improved care for others. The practice took a proactive and staff led approach to safe innovation. There were examples, of staff being encouraged to develop and innovate to improve the safety and quality of the service. For example, the practice pharmacist had increased time dedicated for medicine review appointments to improve medicine optimisation and safety. We saw evidence of this in our analysis of clinical searches within the practice IT system.

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. For example, there was evidence of effective working with the local social prescribing link to address local health inequalities and improve outcomes. The practice also carried out joint visits with the social prescribing link worker to facilitate NHS health checks with the local Gypsy, Roma and Traveller community.

There were systems in place for processing information relating to new patients. The service worked with other providers to deliver shared care and when patients moved between services. Referrals and test results were managed in a timely way.

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 known to staff, who were appropriately trained in safeguarding procedures. The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations. However, we identified through our analysis of clinical searches that the practice did not routinely ensure there was coding to link up where families were subject to safeguarding concerns or actions on patient records. The practice took action to address this quickly after the inspection.

The service always worked well with people to fully understand and manage risks by thinking holistically. They provided care that fully met people’s needs and was safe, supportive and enabled people to do the things that mattered to them. We found there was an open and transparent culture, which encouraged creative thinking in relation to people’s individual safety. For example, the initiative implemented by the pharmacists to offer additional medicine review appointments supported medicines safety and optimisation. The practice supporting early flu vaccination for care home staff and residents, and for housebound patients. This supported healthier lifestyles and reduced the risks associated with influenza in the community.

Emergency equipment was available and maintained. In addition, the practice provided and maintained a public access defibrillator to the exterior of the practice building. This provided an additional life-saving facility available to the community (for example, outside normal practice opening hours) and had been used recently in an emergency.

Staff could recognise a deteriorating patient and knew of action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

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 were maintained. Health and safety risk assessments and audits had been undertaken and risks identified had been addressed. There was a business continuity plan in place which was monitored and reviewed.

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

We found the practice recognised the continuing development of staff skills, competence and knowledge was integral to ensuring high quality care. There was evidence the practice upskilled staff to create additional capacity, skills and experience to meet the needs of patients and create a more flexible workforce. Staff turnover was very low. Since 2019, the practice told us 6 staff had left, of which 3 were due to retirement. There were high levels of staff progressing their careers within the practice. For example, since 2021 they had supported:

• a nurse to become a prescribing advanced nurse practitioner.
• the practice pharmacist was supported to become a prescriber. They were also supported into a part time Primary Care Network (PCN) wide role supporting local pharmacists.
• a health care assistant was supported in training to be a Nursing Associate
• An apprentice receptionist was developed to take up a GP assistant role.
• A receptionist was developed to take up a care coordinator role.
• 2 admin staff undertook phlebotomy training and have clinics within the practice to offer additional choice for patients and support them in maintaining their competence.
• A senior receptionist was supported in developing their leadership skills, with further training planned.
• 2 newly qualified GPs were supported in career start / fellowship program.

There were a range of clinical and non-clinical roles within the practice. We found training was up to date, learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence. Safe recruitment practices were followed.

The practice supported staff to develop capability and competence in managing emergency situations. For example, they had carried out real time simulations of medical emergencies to support staff to know what to do and also identify any areas for improvement. The last exercise focused on an unwell baby, as this can be a more complex medical emergency.

Performance issues and poor performance were dealt with in a timely and appropriate way. There were multiple comments from staff about the excellent support they received, effective supervision and opportunity to develop and progress in their careers.

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 a designated infection, prevention and control lead and all staff had had relevant training. Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks.

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.

Staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely. People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms. Staff received regular training, were competency assessed on medicines optimisation, and felt confident managing the storage, administration and recording of medicines. Staff managed prescription stationery appropriately and securely. Staff followed protocols to ensure they prescribed all medicines safely and supported people to receive recommended medicines reviews and monitoring.

Following feedback relating to the clinical searches we analysed during this assessment, the practice strengthened arrangements to ensure the safe monitoring of medicines. This included noting the day of administration on the prescriptions for a weekly medicine to treat various autoimmune conditions, including rheumatoid arthritis and psoriasis. This reduced the risk of inadvertent daily administration by patients. They also followed up the small number of patients identified at risk of lactic acidosis when prescribed a medicine to manage diabetes whilst they also had potentially impaired kidney function. They also following up the small number of patients prescribed medicine for heart failure who had not had recent monitoring undertaken.

Medicines including controlled drugs were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines, vaccines, and controlled drugs. Waste medicines were recorded and disposed of appropriately including medicines returned by patients. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments. The provider had effective systems to manage and respond to safety alerts and medicine recalls. Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring. Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. Prescribing data reviewed as part of our assessment confirmed this. For example, there was evidence the practice was managing the prescribing of antimicrobials, particularly those most at risk of causing microbial resistance. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.