Dr RC Rautray's Practice

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 has changed to requires improvement. The service is in breach of legal regulations in relation to premises and equipment.

This service scored 56 (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 did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

An independent company carried out a fire risk assessment at the main surgery and branch surgery in December 2025. The report identified several areas of serious and immediate concern, with timescales for the completion of necessary to be completed between the end of January 2026 (for high-risk areas) and the end of March 2026 (for low-risk areas). Although the provider had taken some action, some control measures had not been put in place. These included for some high-risk areas.

Although fire alarms were checked at each site, only 1 person at each site was trained to do this. When these people were not in work the checks were not completed, so there were gaps in records.

An independent company had carried out a health and safety risk assessment at the main surgery and branch surgery in December 2025. This risk assessment also highlighted areas where improvement was necessary, but required actions had not been taken.

Some issues relating to the environment had not been recognised. There was a tear in the flooring in a corridor, which could become a trip hazard. Some doors were labelled “Fire door, keep locked” and these were found to be unlocked. Defibrillator pads had an expiry date of 28 October 2025. Weekly documented checks of the defibrillator had not noted this.

Although the service did record the serial numbers of some prescriptions, this was not well organised. It was not possible to determine what prescriptions were in which printers, and there was no prescription security at the branch site.

The service had a business continuity which had been renewed during 2026.

The practice did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

The service did not follow safe recruitment procedures when employing new staff. We checked the personnel records of 7 staff members, and none of them contained all the required information. Evidence kept by the service indicated that staff were not up to date with mandatory training such as in safeguarding, infection prevention control or fire safety. Appraisals had not been carried out for some staff.

The service did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The infection prevention and control (IPC) policy did not name the IPC lead and did not contain any information about local contacts or relevant information. It mentioned an unconnected service, and the practice manager told us it could have been adopted from another GP practice. The policy did not stipulate how often staff should be trained.

An IPC audit had been completed by the IPC lead in March 2026. It did not contain a total score, and the majority of sections were RAG rated red or amber, indicating a high or medium risk. The IPC lead and manager explained that there was no score as they did not know how to calculate it, and they did not think the risk ratings were correct; they thought their audit was more aligned to hospitals than GP practices.

We found several areas of concern that had not been highlighted in the audit, including several clinical rooms having hand wash basins with plugs on chains. This is an IPC risk. The audit stated there were no hand wash basins with plugs.

We found some out of date equipment and medical supplies at both sites. Although the practice manager told us room checks were carried out, some supplies expired in 2022.

It was difficult to access the cleaner’s cupboard at the main site as a large bag of waste was behind the door. This was a general waste bag, but clinical gloves were coming out of a rip to the side of the bag. Clinical gloves should be disposed of in clinical waste bins. Mops were not stored in a way to promote IPC. They were colour coded, but the mop for isolation cleaning was stored head down touching the mop head for cleaning general areas.

Waste management was not safe. At both sites clinical waste bins were stored outside in areas accessible by the public. They were not locked and contained clinical waste which is a safety risk.

Out of 15 staff, up to date IPC training was not recorded for 8 staff.

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