Well Street 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 people were protected from abuse and avoidable harm.

We identified areas where the provider's systems for overseeing safety were not always effective, as set out in the sections below. However, no evidence of patient harm was identified, no serious incidents had been reported since the last assessment, and there was no history of concerns or enforcement action. The Integrated Care Board and our National Professional Advisor raised no additional concerns and considered the findings to present a low to moderate risk. The provider acted quickly, clearing the identified backlogs and putting new oversight processes in place during and after the assessment. Overall, the concerns reflected gaps in governance rather than unsafe care, and are addressed under the Well-led key question within the Regulation 17 breach.

At our last assessment in January 2016, we rated this key question as Good. At this assessment, the rating has changed to Requires Improvement.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learned to continually identify and embed good practice.

The service had a positive and open culture of safety. Staff were encouraged to raise concerns, and safety incidents were investigated and reported. Lessons were shared to help improve practice. People felt supported to speak up and said staff treated them with compassion and understanding. Managers encouraged staff to report when things went wrong, and clinical issues were discussed in team meetings so everyone could learn from them. Staff told us there was an open culture where safety was a priority. The provider had a Significant Event Analysis (SEA) policy and a Duty of Candour policy, both available to staff on the internal IT system. Staff were able to explain how the service learned from safety events.

The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care.

At the time of inspection, systems for managing test results, referrals and clinical workflow were not always effective. At the time of inspection, we identified 15 high-priority pathology results from 28 January 2026 that had not been viewed, and 161 urgent results from 3 to 17 February 2026 that had been viewed but where required action had not been completed or documented.We also found 481 referrals to secondary care had not been followed up on in the system, with 130 triage responses outstanding. The provider told us the backlog had developed due to staff sickness. However, oversight of these processes was not always sufficient to ensure that work was completed promptly during periods of reduced staffing.

The provider reviewed and cleared the backlogs during and immediately following the assessment, introduced revised daily tracking arrangements and cover protocols for periods of reduced staffing, and submitted evidence of the actions taken. No evidence of patient harm arising from the backlog was identified, and no serious incidents had been reported to CQC. The underlying governance weakness that allowed the backlog to develop is addressed under the Well-led key question and the Regulation 17 breach.

The service did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They did not always share concerns quickly and appropriately.

We reviewed a sample of safeguarding records and found that coding was not always consistent. Child protection alerts were usually recorded on children’s records, but household contacts were not always coded appropriately. In some cases, parents did not have corresponding safeguarding alerts on their own records. In one record, a vulnerability was noted, but no formal alert had been applied, and in another, the incorrect safeguarding code had been used. Recruitment records did not always meet regulatory requirements. We found health declarations were not present in the staff files reviewed, evidence of qualifications was missing in some records, and professional registration had not always been formally verified. We also found that safeguarding training for clinical staff did not meet recommended levels. The practice nurse and healthcare assistant had completed Level 2 safeguarding children training, although staff with regular patient contact should complete Level 3.

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.

Emergency equipment was available and maintained. A defibrillator was located at the ground-floor reception, along with two oxygen cylinders. Staff had completed basic life support training, including adult and paediatric resuscitation, with the majority of clinical staff having completed training within the last 12 months. Staff had completed sepsis training, could recognise a deteriorating patient, and knew the action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated. A duty doctor was available on site every day to manage deteriorating or acutely unwell patients.

The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

During the inspection, two different fire procedures were in use, and one did not include key instructions such as calling the fire service or avoiding use of the lift. Fire marshal training was not complete at the time of inspection. A fire risk assessment had identified a safety concern, but there was no clear evidence that action had been taken to reduce the risk. Records of fire drills were limited, and the lift did not display a warning sign advising people not to use it in the event of a fire. This was also not included in the evacuation procedure. Health and safety risk assessments had been completed, but staff had not been given clear guidance or training on how to follow them. Although daily safety checks were said to take place, these were not recorded, and there was no clear evidence of actions for issues such as loose cables or blind pull cords, which can present a risk of injury.

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.

The practice employed a team of GPs, practice nurses, healthcare assistants, a pharmacist, a practice manager, an assistant practice manager, and administrative and reception staff. Primary Care Network (PCN) staff, including a mental health nurse and social prescriber, were employed by the PCN but not based on site. The practice was appropriately staffed for its patient list size, with GPs at capacity and some administrative vacancies being managed. A supervision policy was in place, reviewed on 2 October 2025. A recruitment policy was in place, last reviewed on 4 March 2025. Training records and meeting minutes for both clinical and administrative staff were available. The mandatory training matrix showed that staff had completed mandatory training across key areas.

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The practice had a designated infection prevention and control (IPC) lead. The environment was clean and tidy. However, during the inspection, daily cleaning checklists for clinical rooms and equipment were not in place, and although refrigerator temperatures were recorded daily, these had not been formally audited. A clinical waste risk assessment was not available, and a RIDDOR (Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013) register was not in place. Staff immunisation records were incomplete for several clinical staff, and where vaccines were absent, there was no documented risk assessment.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

Our clinical searches identified concerns in relation to medication safety and monitoring, including patients prescribed medicines that can cause harm in pregnancy without a documented prevention plan, patients on long-term antiplatelet or anti-inflammatory medicines without appropriate stomach protection, and gaps in monitoring for patients prescribed blood pressure medication. In the asthma search, 4 out of 5 patients had not received appropriate follow-up after an exacerbation, and in the medicine review search, 3 out of 5 reviews were not completed to an acceptable standard. Cold chain monitoring was in place; however, there was no separate audit process to provide assurance that requirements were consistently met. A standalone medicines audit had not been implemented. Emergency medicines had been periodically reviewed by clinicians, but these checks were not documented, and there was no associated risk assessment to support the level of emergency medicines held. In addition, a controlled drugs policy was not in place at the time of inspection.