The Park 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.

The service was in breach of legal regulation in relation to fire safety, infection prevention and control and safe storage of vaccines.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

A representative from the Patient Participation Group (PPG) felt the provider took concerns seriously and proactively made improvements to the service.

The provider had processes for staff to report incidents, near misses and safety events. Managers encouraged staff to raise concerns when things went wrong. During meetings, the clinical team discussed and learnt from clinical issues. Staff felt able to report incidents and the managers told us there was a no blame culture. Although incident records and outcomes were well recorded and available for all staff to view electronically some staff felt the outcomes of incident investigation were not always shared with them. A significant incident review analysis had been completed and had identified pattens and trends in some administrative tasks and the dispensary. The provider had taken action to improve by providing additional training and supervision for staff and further development of policies and procedures.

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 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.

The service worked with other providers to deliver shared care, and they had a dedicated member of staff who supported this process and who liaised with secondary care providers and patients when necessary. The service had provided information for patients, via social media, which described the role and responsibilities of the GP practice and secondary care in prescribing to address concerns raised by patients.

There were systems in place for processing information relating to new patients. 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.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Emergency equipment was available and maintained. 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 practice had undertaken audits to identify patients under 11 years old who attended the practice and/or A and E frequently. They had had worked with other agencies in neighbourhood teams to provide information and provided a ’when should I worry text’ to parents and guardians and highlighted this area in a social media campaign.

The service did not always detect and control potential fire risks in the care environment. They had mostly 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 to cover most areas and risks identified had mostly been addressed. However, fire safety risks had not always been identified and managed. The store cupboard with the electrical fuse box had flammable items such as cardboard boxes and paper rolls and the fuse box door was open. This was identified to the manager, and the cupboard had been mostly cleared by the end of the assessment although some items stored in cardboard boxes remained and the manager told us this would be addressed. A fire risk assessment was in place for the main site but not for the branch surgery and this did not identify all risks such as the evacuation chair on the first floor. There was a system to check the fire equipment regularly but the fire alarm checks at the main site had not been completed consistently on a weekly basis. For example, the records showed the last test had been completed on 24 July 2025. Prior to this it had been completed on the 2 July 2025, and the fire alarm had only been checked twice in June and three times in May. The monthly emergency lighting tests had been completed twice in 2025 and three times in 2024.

There was a business continuity plan in place which was monitored and reviewed.

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

The practice had been through a significant period of change and had seen a high turnover of staff in the last 18 months; the provider had recruited to the vacant posts. Additional staff, including two salaried GPs, were due to commence employment. Staff told us it had been a difficult period whilst they covered the vacancies within their teams and, although new staff were still undergoing training, they reported they were now in a more stable position. The staff worked in specific teams each with a team leader who they found supportive. The provider told us they were hoping to recruit to the nursing team leader role. This role was currently covered by the practice manager and GPs.

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. Most staff told us they had received annual appraisals and there was an electronic system to record and monitor appraisals. Safe recruitment practices were followed. An operations manager had recently been employed, and part of their role was to review all processes relating to staffing.

The service assessed the risk of infection but did not always manage the risk effectively.

The practice had a designated infection, prevention and control (IPC) lead and staff had received relevant training. Cleaning schedules were in place and followed by the external cleaning company. There was a cleaning schedule for cleaning clinical rooms completed by the nursing team although they told us they did not have a cleaning check list to ensure consistency. A new IPC audit package had been purchased and implemented, and the lead member of staff had attended training relevant to this new process. Audits had been completed but action plans had not been developed to ensure risks identified were mitigated. The shelves on some trolleys used in the clinical rooms were cracked and some had remnants of old tape which may impact on effective cleaning. The building at the main site was in good repair and clean and tidy. The building at the branch site was clean but had some paint missing from the wall. The practice had a shower at the main site, which was infrequently used, systems to purge seldom used water outlets was in place as part of the system to mitigate risk related to Legionella. The shower was not included in the Legionella check records related to purging seldom used outlets.

The service always made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They always 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 followed protocols to ensure they prescribed all medicines safely, and ensured people received all recommended medicines reviews and monitoring. Medicines including controlled drugs were stored securely.

Vaccine fridge temperatures were recorded twice daily, and data loggers were provided inside the medicine fridges to enable detailed temperature tracking. There were policies and procedures which identified the appropriate action to take if incidents of fridge temperatures being out of the required range (an excursion) had been identified. Records showed that one incident of a fridge temperature excursion had been investigated, and appropriate action had been immediately taken to minimise risk. However, on three other occasions when the temperature was out of range limited records had been maintained and there was a lack of evidence that these incidents had been investigated, and risks had been minimised. Data logger records for these periods were not accessible on the day of the assessment due to the way they had been stored electronically. Monthly audits were in place to monitor the fridge, and the records completed, but these had not been completed consistently. The manager told us they would investigate these incidents.

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 most medical gases, such as oxygen, safely although one small oxygen cylinder was not appropriately secured and protected from accidental damage. The practice manager told us they would address this.

The provider had effective systems to manage and respond to safety alerts and medicine recalls. Staff followed established processes to ensure people who were prescribed medicines with specific risks received recommended monitoring and our clinical searches confirmed this.

There was an extensive programme of regular clinical audits of prescribing that focused on improving care and treatment. 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, the number of antimicrobials issued by the provider was lower than local and national averages and trends over time showed the practice had performed well in this area for several years. Other areas of prescribing data for medicines such as opioids and hypnotics also showed the practice performed well compared to national averages and that they had also maintained this performance over several years.

The practice had a dispensary at the main site. There were suitable processes for staff to follow when dispensing medicines which had been recently reviewed and updated. Following incidents in dispensing a review was undertaken and additional staff training and oversight was implemented. Patients told us there had been significant improvement in dispensing of medicines recently.

The provider had acted on feedback from patients in relation to the dispensary. For example, patients had fed back that they were having difficulty collecting medicines within working hours and the provider had arranged a medicine vending machine to be installed by September 2025. This will enable patients to collect medicines 24 hours a day.