Dr J Sullivan & Partners Also known as Moorside 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 66 (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 always make sure equipment, facilities and technology supported the delivery of safe care.

There were some processes in place for premises maintenance and for health and safety risk management, such as equipment calibration, and gas safety checks. However, remedial actions arising from maintenance checks and risk assessments were not always actioned in a timely manner. For example, an electrical installation condition report from January 2023 showed that the system was unsatisfactory, with required high-risk actions identified. However, at the time of the assessment these actions had not been addressed. In addition, a fire risk assessment carried out in March 2025 identified further required remedial measures, including a significant risk related to the absence of evacuation drills. However, at the time of the assessment these actions also remained outstanding. In mitigation of this, we saw that there were some processes in place to control risks associated with fire which included the servicing of fire extinguishers and the testing and maintenance of fire alarms. Furthermore, although a Legionella risk assessment had been carried out, and regular water temperature testing was in place, no immediate action had been taken where temperatures were found to be out of the required range. After our visit we saw that all high-risk remedial works had been completed, and a fire evacuation drill had taken place.

The service had a business continuity plan which outlined how the service should continue to operate in the event of a disruption.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support and development. They worked together well to provide safe care that met people’s individual needs. However, there were no formal, documented clinical supervision sessions in place for clinical staff. There was evidence of prescribing audits carried out. Staff told us that support was readily available as needed, and that regular meetings provided opportunities to discuss cases and seek advice. In addition, while staff appraisals were undertaken, some had not been completed within the expected timeframe and were significantly overdue. Following the assessment, the service implemented a policy to provide regular, documented clinical supervision sessions for all clinical staff, and had arranged for necessary appraisals to be undertaken.

The service included a range of clinical and non-clinical roles, which included GPs, nurses, and healthcare assistants.

Staff were largely up to date with mandatory training, however training in learning disability and autism had not been completed. In addition, certain role-specific training had not been completed, including training for designated fire wardens in the use of evacuation aids. We were told that this training would be completed within the next month.

The service followed safe recruitment procedures when employing staff, which was in line with national legislation. This included identity checks, review of qualifications, obtaining professional references and a criminal records check.

The service did not always appropriately assess or manage the risk of infection.

The service had some arrangements in place to maintain a clean and tidy environment, including the use of external cleaning contractors. However, during the site visit visible dust was observed in some areas and there was limited assurance available regarding the effectiveness, frequency, and oversight of cleaning arrangements. After the assessment the service provided more clarity around this and advised us that an independent audit of cleaning arrangements would be undertaken.

An infection prevention and control (IPC) lead was in place, and internal IPC audits were completed annually. While actions identified through this audit had been completed or were in progress, the findings on the day indicated that audit processes were not sufficiently robust, or frequent enough to identify all IPC risks. This included the presence of damaged and non-wipeable chairs within clinical rooms, which had not been identified through audit. The service told us that new chairs would be ordered as required.

Staff had completed relevant training in infection prevention and control.

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