Peartree 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 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 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 practice did not always have a proactive and positive culture of safety based on openness and honesty. They listened to concerns about safety and investigated and reported safety events however lessons were not always learnt to continually identify and embed good practice. Managers encouraged staff to raise concerns when things went wrong and there are processes for staff to report incidents, near misses and safety events. Analysis of significant events reviewed saw recorded and investigated events however there was little evidence of how the learning had been shared with the staff. A complaints policy dated February 2024 was in place, along with a system to record complaints and incidents when things went wrong. However, it was identified that the practice did not consistently follow its own complaints policy, particularly in relation to the investigation of complaints. We were not assured that the provider had followed all steps outlined in their policy. Representatives from the PPG felt the provider took concerns seriously and proactively made improvements to the practice. Staff felt there was an open and positive culture, and staff told us they felt listened to.

The practice worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed and monitored. They made sure there was continuity of care, including when people moved between different practices.There were systems in place for processing information relating to new patients. For example, all summarisation records were up to date for new patients. The practice worked with other providers to deliver shared care and when patients moved between practices such as staff worked closely with a local hospice provider supporting patients receiving end of life. Referrals and test results were managed in a timely way.

The practice 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 practice shared concerns quickly and appropriately. Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. The provider made sure that children had been appropriately followed up when they failed to attend appointments with primary or secondary care practices. The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations. For example, all housebound vulnerable patients were visited and looked after by offering home vaccinations, blood tests, blood pressure monitoring and general wellbeing checks.

The practice 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. For example, the practice carried out audits to ensure the urgent cancer referrals had been booked with secondary care providers as a safety netting mechanism Emergency equipment was in a ‘grab bag’ which was easy to transport anywhere in the building or externally. Emergency medicines were located with the emergency equipment and stored appropriately. The clinical staff completed monthly checks of equipment and medicines, and these were recorded and audited. Staff could recognise a deteriorating patient and knew of action to take. The reception desk was in clear view of the patient waiting room. There was a poster in the reception area explaining the process how to request chaperone assistance, if needed.

The practice detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Contracts were in place to ensure the premises were maintained. For example, the provider had a Legionella certificate which was completed September 2024. There was also evidence of monthly water temperatures being tested and this had last been completed June 2025. Health and safety risk assessments and audits had been undertaken and risks identified had been addressed. There was a business continuity plan in place which was monitored and reviewed. It was observed that staff removed their SMART cards when leaving their computers. This ensured that the computer is locked, and access is therefore restricted. Fire extinguishers were in date with annual servicing. Electrical appliances had been tested for safety, and these were dated October 2024. The provider had a Fire Risk assessment dated October 2024 however when this was reviewed actions had not been updated. The provider addressed this immediately and assurances were given.

The practice did not always make sure there were effective systems in place to support safe recruitment. Six recruitment records we reviewed had missing evidence in several areas, including references, health declarations, appraisals, and explanations for gaps in employment. For example, the appraisal policy dated 13 July 2025 refers to annual appraisals and regular reviews throughout the year. However, there was no evidence of this process documented in the staff records’ The staff files were difficult to navigate and not clearly indexed. The provider had a Disclosure and Barring Service (DBS) policy dated 2 April 2025, which stated that non-clinical staff were not required to have a DBS check. As a result, the provider had implemented a risk assessment process for these staff members. However, there were no records to show that the risk assessments had been completed for non-clinical staff ‘The same applied to lone working risk assessments. The practice had a template in place for this however staff had not completed one. The practice has since sent assurances that these would be reviewed immediately. There were a range of clinical and non-clinical roles within the practice and there was good evidence of clinical supervisions being completed. We found training was up to date with learning needs and development of staff managed appropriately, ensuring that staff worked within their agreed areas of competence. The practice used Locums GPs and there was good evidence of their induction process. Records for locum staff, including references and DBS checks, were also available and well maintained.

The practice assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. The practice had a designated infection, prevention and control lead and all staff had had relevant training. Cleaning schedules were in place and followed. Cleaning data sheets were present for most cleaning products. The cleaning equipment was in good condition however there was no evidence of deep cleaning of the carpet on the first floor. Monthly water temperatures were completed. Staff immunisations records were in place however they were not within individual staff records and no evidence of review. Risk assessments and audits were completed, however there was no written evidence of the review of actions for example the recent infection prevention control audits didn’t have updated actions recorded.

The practice made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. 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 managed prescription stationery appropriately and securely. They involved people in planning, including when changes happened. The practice maintained appropriate fridge temperature records where vaccines were being stored and observation of variances of temperature had been addressed and logged. Medicines including controlled drugs were stored securely and at appropriate temperatures. 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 medical gases, such as oxygen, safely and completed required safety risk assessments. Emergency medicines storage did not hold some medications for example diazepam and midazolam however the provider was able to evidence there was an emergency medicines supply agreement dated November 2024 with the attached Pharmacy to provide this should it be needed. During our onsite visit we found discrepancies with the Patient Group directives (PGDs) for example the blank signature lines had not been scored out as detailed in the guidance. Staff had added their signature after the authorising date. The provider immediately sent assurances that this would be rectified with immediate effect. The clinical searches reviewed patients prescribed antibiotics and this was found to be safe and no concerns were raised. The clinical searches highlighted the practice recall system didn’t always capture patients who did not respond for example patients who are monitored for Hypothyroidism and blood pressure annual reviews. The practice has sent us an update detailing all patients have been recalled including consideration for alternative ways to promote this moving forward.