St Mary's 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 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 premises in which the service was based was managed and owned by a third party. The provider had in place a contract that illustrated what they were responsible for. We saw that staff and leaders completed health and safety risk assessments, undertook audits and we saw that equipment calibration and Portable Appliance Testing (PAT) were in place to ensure they had identified and addressed any risks to patient safety. We saw that a business continuity plan was in place and it identified what actions would be required in the event there was disruption to the service.

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.

There were clinical and non-clinical roles, which included GPs, nurses, pharmacists and a health care assistant and staff also employed by Primary Care Network (PCN). Leaders ensured there were mechanisms in place to ensure all staff were up to date with mandatory training the service deemed was a priority. The service had in place a recruitment process which was in line with national legislation. We saw that the process was used when staff were recruited and the following checks were also carried out, including identity checks, review of qualifications, obtaining of professional references, and a Disclosure and Barring Service (DBS) 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.

We saw that the appropriate processes were in place, so the environment was kept clean and any areas that needed to be sterile were done. Where equipment was needed to be kept clean, staff had the appropriate guidance in place, so this was carried out effectively. The service demonstrated how they monitored/had oversight. During our onsite visit, the premises and equipment was visibly clean. The service’s infection prevention and control lead conducted regular risk assessments and audits to ensure compliance and took action where necessary to mitigate any identified risks. Staff had completed relevant training in infection prevention and control.

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