The Shrubberies Medical Centre

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.

The premises were leased, but maintenance was managed by the practice. On the day of inspection, the premises and equipment were clean, well-maintained and suitable for service delivery. The provider had systems to manage environmental risks. Fire safety arrangements, water and electrical safety oversight, and equipment servicing and calibration were completed in line with the practice's schedule. Emergency medicines and resuscitation equipment were regularly checked and were within their expiry dates. Systems were in place for the safe management of clinical waste, hazardous substances and prescription stationery. Appropriate prescription security measures were observed. The provider maintained an environmental risk register, monitored control measures and undertook audits to identify and address risks. Staff told us they had access to suitable equipment and a safe working environment. The service had assessed the accessibility of the premises, including step-free access, wheelchair-accessible entrances, a hearing loop and accessible emergency exits. Areas identified for improvement had been included in an action plan. The service also had a regularly reviewed business continuity plan.

The service 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 employed a range of clinical and non-clinical staff and had a staffing structure to support service delivery. Most staff had worked at the practice for a number of years, supporting workforce stability and continuity of care. Recruitment records showed appropriate pre-employment checks had been completed. Completed induction records were available, and staff understood their roles and responsibilities. Locum staff received supervision and their performance was monitored through audits. Staff told us locum cover was arranged when required to maintain service delivery. Staff meeting minutes included discussions about training needs, and a staff survey completed in May 2026 identified a need for additional support with training and development. An action plan had been developed in response. Overall, while there were some positive elements of staffing structure with staff engagement, the evidence demonstrated shortfalls in key workforce governance processes. For example, appraisal records were not available to demonstrate staff received regular performance reviews and development discussions. Of the five personnel files reviewed, only one contained evidence of an appraisal completed in 2023. The mandatory training matrix did not accurately reflect training completed by staff, limiting oversight of training compliance. Physical and mental health declarations were not consistently available within personnel records. These issues reduced assurance that workforce governance arrangements were effective.

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 systems and processes to prevent and control infection. An infection prevention and control (IPC) lead had been identified, and supporting policies and cleaning arrangements were in place. Staff had received appropriate training. The provider monitored IPC risks through audits and took action to address identified issues. Records demonstrated appropriate arrangements for the management of waste, sharps and decontamination processes. Patient participation group meeting minutes showed concerns about pigeon droppings outside the premises had been raised and acted upon through an improvement plan. During our inspection, the premises and equipment reviewed were visibly clean. Cleaning schedules were present and followed. We observed safe IPC practices, including appropriate hand hygiene and use of personal protective equipment. Staff demonstrated an understanding of IPC procedures, including the notifiable disease reporting procedure, and patient feedback about cleanliness was positive.

However, records relating to curtain changing and daily clinical room and equipment cleaning checks were not available on site at the time of our assessment. The provider acknowledged this and took action to address it.

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