The Borchardt Medical Centre

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 staff protected people from avoidable harm and made sure care was delivered from environments that were clean and well maintained. At our last assessment, we rated this key question as good. At this assessment, the rating remains the same.

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.

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

Staffing arrangements were planned in advance to support service delivery. Rotas were reviewed proactively and staffing levels were monitored to cover annual leave and absences. Leaders told us there were currently no recruitment gaps. Staff had access to mandatory and role-specific training through an online platform, with protected learning time provided. Staff received appraisals and described management as approachable and supportive. However, we found that some mandatory training had not been completed by staff, including autism awareness, basic life support and infection control. An up-to-date training matrix was sent in after the inspection to confirm that the mandatory training had now been completed.

The service followed safe recruitment procedures when employing staff, which were 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 practice had arrangements to support infection prevention and control. The practice completed annual infection control audits, and the most recent audit achieved a score of 99%. Staff received annual IPC training and understood that infection prevention was everyone's responsibility, and a designated infection control lead was in place. Legionella risk assessments had been completed, and monitoring arrangements were in place. However, we identified some concerns. Water monitoring records showed temperatures remained below recommended levels and there was no documented action plan to address this. The practice confirmed to us on the day of inspection that they would have this issue investigated and would provide evidence once it was resolved. We also found some syringes and saline in the emergency drugs bag that were out of date which were removed immediately by the practice.

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