Wallington Family 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 Requires Improvement. At this assessment, the rating has changed to good.

The service had a good learning culture and people could raise concerns. Managers investigated incidents thoroughly. People were protected and kept safe. Staff understood and managed risks. The facilities and equipment met the needs of people, were clean and well-maintained and any risks mitigated. There were enough staff with the right skills, qualifications and experience. Managers made sure staff received training and regular appraisals to maintain high-quality care. Staff managed medicines well and involved people in planning any changes.

The service was in breach of legal regulation 17 (Good governance) and is no longer in breach.

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.

At the previous inspection we found that the practice did not have a consistent and effective system to learn and make improvements when things went wrong. During this inspection we found the practice had implemented a better system to learn and make improvements. For example, documentation relating to incidents we reviewed showed the practice was recording what and, why it happened; what went well and what could be done better; as well as learning points which were discussed in meetings. However, there was still room for development in terms of the practice further exploring learning and identifying trends and themes to prevent recurring significant events/complaints.

The service had a proactive and positive culture of safety, based on openness and honesty. All staff including non-clinical were made aware of significant events.

They listened to concerns about safety and investigated and reported safety events. The significant event policy had been reviewed in August 2025 and was kept on an electronic platform that the practice used to store all documents which all staff could access.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. Staff we spoke with indicated they were happy with the way the practice responded to and supported them when things went wrong. There were systems in place to ensure learning was shared.

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

Managers encouraged staff to raise concerns when things went wrong. During staff meetings, the whole team discussed and learnt from clinical issues. Staff felt there was an open culture, and that safety was a top priority. The provider had processes for staff to report incidents, near misses and safety events.

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. We saw that complaints were discussed in clinical meetings, as well as monthly all staff meetings.

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.

There were systems in place for processing information relating to new patients. The service worked with other providers to deliver shared care and when patients moved between services. Staff informed us alerts were put on the electronic patient management system. All discharge summaries came through the patient management system and if clinicians needed to view them, a task would be sent to relevant staff member. Referrals and test results were managed in a timely way. All clinical staff did their own referrals on the day, admin staff would follow up if a referral had been rejected, clinical staff said they had good communication with the admin team.

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. We saw separate polices that covered children and adults, these had been reviewed in March 2025. All staff knew and understood the policies content. There were two safeguarding leads one for children and one for adults. The leads covered for each other when either was away. All staff knew who the safeguarding leads were. The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations. For example, the practice had quarterly safeguarding meetings with the health visitor, where they would discuss all patients on the register.

All staff we spoke with demonstrated a comprehensive knowledge of safeguarding. All GPs, and nurses completed training to level 3. All other staff completed training to level 2.

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.

Data from the GP Patient survey 2025 showed a total of 91% of respondents stating they were involved as much as they wanted to be in decisions about their care and treatment during their last general practice appointment. This was in line with the local average of 92% and national average of 91%. Ninety percent of respondents felt their needs were met during their last general practice appointment. This was in line the local average of 91% and national average of 90%.

At the last inspection the practice did not stock all of the emergency medicines recommended by guidance. At this inspection we identified no concerns with the emergency medicines.

Emergency equipment was available and maintained. This included a defibrillator and oxygen. Appropriate emergency medicines were also available. They were checked weekly; and all documented on the practice electronic system.

Staff could recognise a deteriorating patient and knew of action to take. This included staff being trained to identify patients who may have sepsis and how to access urgent help if needed. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

At the previous inspection, improvements were required in relation to the fire risk assessment. At this inspection, we saw an appropriate fire risk assessment had been completed in August 2025. There were two actions which had been dealt with. We saw a log of fire drills which were completed every six months. The most recent fire drill of the building was undertaken in August 2025. The practice manager was working closely with the other tenants in the building collaborating the undertaking of fire drills and risk assessments.

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 practice manager had good oversight of the maintenance contracts in place. We saw that fire, and electrical maintenance contracts were well monitored, and checks were carried out in a timely manner. We saw a certificate for Portable Appliance Testing (PAT) equipment dated November 2024. We saw certificates for calibration of equipment dated November 2024; we were told any equipment that had not passed was taken out of action. The practice had a rolling contract so every 12 months equipment would be tested.

At the previous inspection there were gaps in staff recruitment files, so we were not assured that the practice was following safer recruitment practices. During this inspection we saw that safe recruitment practices were generally followed. We reviewed 5 staff records which demonstrated this practice. However, we found that it was unclear whether the team was aware of the requirement to request Right to Work checks for colleagues from European countries.

The practice carried out enhanced disclosure and barring services checks for all clinical staff and for non-clinical staff who chaperoned. All other non-clinical staff had basic disclosures.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development.

We identified that 2 staff members did not have an appraisal, when we raised this with the practice, they were aware and had the staff members scheduled to have an appraisal shortly after the inspection.

They worked together well to provide safe care that met people’s individual needs.

There were a range of clinical and non-clinical roles within the practice. For example, the practice had two non-medical prescribers that had weekly supervision initially when they joined the practice. This was then reduced to every two weeks and then monthly once the staff members and supervising GP felt competent with their prescribing. We were told there was an open-door policy and staff were always welcome to discuss anything.

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. Safe recruitment practices were followed.

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.

At the previous inspection the practice did not have appropriate systems for monitoring infection control. At the current inspection we found the practice had effective systems in place to monitor infection control. For example, they had introduced a structured cleaning schedule which was on the back of all clinical doors which were signed and dated by staff.

At the previous inspection 3 staff files we reviewed did not have evidence of staff immunisations. At the current inspection we reviewed 5 staff files and all files had evidence of staff immunisation. We were told for any staff members who did not have evidence of immunisation a risk assessment would be done, and if staff did not want a vaccination, they would get staff to sign a declaration.

Risk assessments and audits were completed, and actions taken to mitigate risks. The last infection control audit was completed during August to September 2025, no major concerns were identified, and all actions had been addressed. For example, replacing a chair that had a rip. All rooms had sufficient supplies of liquid soap and paper hand towels. The taps in clinical rooms were lever operated to avoid the risk of re-contamination.

All staff had completed infection control training. The practice had a designated infection, prevention and control lead and all staff had had relevant training. Cleaning schedules were in place and followed.

At the previous inspection we found medicine reviews were not always done effectively. Some patients were overdue appropriate (reviews) monitoring. There was no formal documented system to monitor the prescribing of controlled drugs. The practice did not stock all of the emergency medicines recommended by guidance.

At this inspection, we found that the provider had effective systems in place for medicines reviews and patients were coded appropriately. Patients had appropriate monitoring and there was a formal documented system to monitor the prescribing of controlled drugs.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They 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.

At the previous inspection we found that receipt and issue of blank prescription stationary was not being recorded. At this inspection staff told us about the system used for blank prescriptions. All prescriptions were removed from clinical rooms daily and locked away in a secure cupboard, a folder was now in place where records of prescriptions were documented, signed and dated and could be clearly tracked and traced.

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 and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines, vaccines, and controlled drugs. We saw the logs of the weekly and monthly checks completed by staff.

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. The provider had effective systems to manage and respond to safety alerts and medicine recalls. Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring. Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics.