Nethergreen 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. This was a focused assessment, which meant we did not assess all quality statements. Our rating is determined from the findings of both this assessment and our previous assessment(s). At our last assessment, we rated this key question as good and this remains unchanged due to the focused nature of this assessment. However, updated quality statement scores have been issued where relevant.

This service scored 72 (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 were maintained.

Staff and leaders completed health and safety risk assessments and undertook audits to ensure they had identified and addressed all risks. Appropriate systems were in place for safe storage of blank prescription stationery, and the provider had effective systems to manage and respond to safety and medicine alerts. 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.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support and supervision although oversight of staff training and induction processes required review.

The provider (GP partners) employed a range of clinical and non-clinical roles, which included salaried GPs, an advanced nurse practitioner, nurses, healthcare assistants, a nurse associate, an advanced paramedic practitioner, a pharmacist, practice manager and a team of administrative, secretarial and reception staff. The service also supported GP registrars in training. They worked together well to provide safe care that met people’s individual needs. However, leaders were not assured that all staff were up to date with mandatory training in line with the service’s training policy. Several staff members were overdue for annual information governance training, although we observed this had been scheduled for 13 May 2026. Four of the six nursing staff were overdue for annual Infection Prevention and Control (IPC) training. In addition, the monitoring log did not distinguish if safeguarding training was for child, adult or both or the level trained to and leaders were unable to confirm the most recent completion date of adult safeguarding training for two GPs, and one GP was recorded on the training matrix as having completed Level 2 rather than the required Level 3 training. The service had an induction programme in place for new staff; however, leaders did not effectively monitor or have sufficient oversight of staff progress through this programme. The timescales for completing mandatory training were not clearly defined or managed, and as a result, leaders could not be assured that staff had completed their initial mandatory training within an appropriate timeframe. Following the assessment, the practice manager took prompt action to improve the clarity of the training monitoring spreadsheet and to ensure staff compliance with the training policy. GPs for whom safeguarding update training could not be evidenced completed the required training at the appropriate level immediately after the assessment.

Staff operated within their agreed areas of competence and had regular clinical supervision and annual appraisals. 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.

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 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 and there was a maintenance schedule for repairs and replacing items such as a medical couch which had a small tear identified. The service conducted regular risk assessments and audits to ensure compliance and took action where necessary to mitigate any identified risks. The service maintained records of staff immunisation status. The practice manager had identified several months earlier that the information recorded did not fully meet national recommendations; however, action had since been taken to obtain the required information and had completed risk assessments where this was not available. Staff had completed relevant infection prevention and control training; however, as the policy requires annual updates for clinical staff, 4 of the 6 nursing staff were overdue. The practice manager advised that training updates would be arranged immediately.

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