Hill Barton 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. At our last assessment, we rated this key question as Good. At this assessment, the rating remains the same.

This service scored 69 (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.

Staff and leaders completed health and safety risk assessments and undertook audits to ensure they had identified and addressed all risks. For example, daily, weekly and monthly checks of the premises were carried out.

The service had an up to date fire risk assessment dated March 2026. Staff conducted weekly fire tests, were trained in fire safety and there were trained fire marshals available at the service.

The service held contracts to ensure the premises was maintained. For example, gas and electrical equipment had annual servicing and medical equipment was calibrated in line with manufacturers recommendations. Safety alerts relating to equipment were shared with the relevant staff and acted on. Portable appliances were tested on an annual basis. Records we viewed showed the service completed maintenance checks in line with requirements.

The service had a business continuity plan which leaders reviewed regularly and outlined how the service should continue to operate in the event of a disruption.

The service was accessible for all people and included space for wheelchairs and prams. Hallways and corridors were clean and tidy and free from clutter. Staff offices were secure, and access was restricted from the public.

The service had not ensured all staff had completed training that it deemed as mandatory. However, the service had made sure there were enough qualified, skilled and experienced staff. They made sure staff received effective support and supervision. They worked together well to provide safe care that met people’s individual needs.

Not all staff were up to date with training which the service had deemed mandatory. For example, moving and handling for clinicians, only 16% of staff had completed (2 out of 5), whilst the bullying and harassment module, only 50% of staff had completed (6 out of 12) and information governance, only 75% of staff had completed (8 out of 12). We reviewed the service’s policy for mandatory training which stated, “all staff at this organisation were expected to partake in all arranged mandatory training events”. The service had recognised this and, following our onsite visit, were reviewing training guidance from multiple sources who provide information on mandatory training in healthcare settings. Additionally, the service had implemented an action plan to ensure all staff had completed current mandatory training within the next 2 months.

However, the service employed a range of clinical and non-clinical roles, which included GPs, nurses and administrative staff.

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.

Staff worked within their agreed areas of competence. Staff told us their development and support were a priority to management, and staff had developed into additional lead roles. Staff were encouraged to access additional training they felt would support their development. All staff had annual appraisals that focussed on development and staff wellbeing.

The service had not ensured all staff had received appropriate training in infection prevention and control (IPC), nor had it managed the safety of clinical waste appropriately. However, they detected and controlled the risk of infection spreading and shared concerns with appropriate agencies promptly.

The service’s IPC lead had not undertaken the level of training in infection and prevention control to support them to carry out their role. The service had already recognised this and had booked training to occur within the next 6 months, due to the availability of recognised or accredited training courses. Whilst waiting for the training, the IPC lead attended IPC forums to ensure they were up to date with current guidance. Additionally, only 75% (9 out of 12) of staff had completed their refresher training in infection prevention and control. The service had recognised this had implemented an action plan to ensure all staff had completed this training within the next 2 months.

The service had obtained a new external clinical waste bin approximately one week before our onsite visit, which had not been securely stored in line with national guidance. We raised this with the service at the time of our visit, who provided evidence to show this would be actioned once the required equipment had been sourced.

We identified that fabric curtains were in use in clinical areas. Timeframes were set out for curtains to be laundered to minimise the risk of infection, but the service could not evidence they had been laundered the curtains in line with IPC guidance. Environmental cleaning schedules were available in only 1 of 4 clinical rooms. However, we noted the curtains and clinical rooms to be clean and free from dust during our visit.

However, 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’s IPC lead conducted regular risk assessments and audits to ensure compliance and acted where necessary to mitigate any identified risks.

The service held records of staff immunisations, to ensure staff and people using the service were protected against infectious diseases. During our visit, the service's premises and a sample of equipment reviewed was noted to be visibly clean. Clinical rooms had adequate provision of personal protective equipment (PPE) and handwashing facilities. Audits were undertaken on hand hygiene on a regular basis, to make sure staff used effective techniques to maintain hand cleanliness.

The service had cleaning protocols available, which outlined how staff should clean the building and its equipment. Cleaners maintained records of daily and weekly tasks they completed, these were reviewed by the service. A communication book was used so the service could inform cleaners of any concerns, and the cleaners were able to respond to these. The service carried out monthly audits of cleaning arrangements.

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