Dr Philip West Also known as Boundaries 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 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 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 service had contracts to ensure the premises was maintained. Staff and leaders completed health and safety risk assessments and undertook audits to ensure they had identified and addressed all risks. Premises risk assessments identified the environment remained safe for people, despite some areas of the building requiring renovation, including ceiling and roof repairs in one part of the premises, as well as residual damp and flooring issues within the treatment room. There were ongoing development plans to renovate the premises and risks were mitigated while these plans were carried out. The service had a business continuity plan which was regularly reviewed and outlined how the service should continue to operate in the event of a disruption.

There were fire safety measures, including regular fire alarm testing, servicing of fire extinguishers, and gas safety checks, with schedules outlined in the fire safety policy. The service had carried out a fire risk assessment in April 2026. Actions had been taken to ensure the premises was safe and complied with the Fire Safety Act 2021.

The service had retained and stored all Control of Substances Hazardous to Health (COSHH) risk assessments for all cleaning products stocked, alongside relevant Safety Data Sheets (SDS).

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, paramedics and pharmacists. Leaders ensured staff were up to date with their training which the service had deemed mandatory and operated within their agreed areas of competence. Rotas were planned up to between 4-5 weeks ahead of time. Thie enabled clinical and administrative staff to be managed effectively to ensure service capacity was met across the service. There were staffing arrangements to manage emergencies safely and prevent lone working.

There were systems to monitor staff training compliance, and we noted all staff had completed mandatory training in line with service policy.

The service followed safe recruitment procedures when employing staff, which was in line with national legislation. This included identity checks, review of qualifications, obtaining of professional references and a criminal records check. However, records did not always retain job interview summaries to demonstrate the suitability of recruitment of staff. Records did not contain physical and mental health information for staff upon recruitment but had access to occupational services which supported staff through workplace assessments where required. The service also did not always retain probation and induction documents to demonstrate staff had been appropriately supported, assessed, and deemed competent for their roles until their scheduled appraisals. From the records we reviewed during the site visit, we noted appraisals had taken place routinely and documented staff competency and performance, whilst identifying learning and development needs. Staff we spoke with during the site visit told us they were confident in their roles and felt supported to raise concerns, including training needs, understanding their responsibilities, and working in line with service policies. The service had an improvement plan which included the digitisation of human resource records, to ensure all pre-employment checks such as job interview summaries as well as induction and probation documents to be held electronically. The service was working toward implementing these processes as part of their existing training and finance system.

Although staff could describe processes to support health and safety, staff risk assessments and documented reasonable adjustments had not always been retained to demonstrate oversight for all staff members. For example, annual Display Screen Equipment (DSE) assessments and movement and handling risk assessments. This meant there was a risk staff were working without clear guidance on safe techniques or equipment. Leaders told us there were ongoing plans to manage and oversee regularly reviewed staff risk assessments as part of the service’s development plan.

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 cleaning schedules available, which outlined how staff should clean the building and its equipment. The service demonstrated how these were monitored for completion to maintain oversight of cleaning arrangements. During our onsite visit, the service's premises and a sample of equipment reviewed was noted to be visibly clean. The service’s infection prevention and control lead conducted regular risk assessments and audits, such as cleaning standards and hand hygiene audits, to ensure compliance and took action where necessary to mitigate any identified risks. Cleaning schedules were in place and followed with audits of performance reviewed with the cleaning contractor. Clinical waste arrangements were effective to ensure safe storage and appropriate labelling in line with infection prevention and control national guidelines

The service had carried out a legionella service assessment in January 2026. The service had a monthly water temperature sampling regime to demonstrate water temperatures were controlled to prevent the growth of legionella bacteria in line with national guidelines.

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