Statham Grove 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 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. For example, the service did not have an effective system to monitor risks relating to health and safety.

Health and safety audits and risk assessments, including fire safety, electrical and Legionella had been completed within the past 12 months, however, not all identified risks had been addressed. For example, recommendations from the fire safety risk assessment in April 2025, had only been partially followed up and we found that one significant fire safety risk identified regarding the loft space, was not being managed effectively. In addition

the practice did not have an effective mechanism to monitor progress with the fire assessor’s recommendations. Immediately following this assessment, the provider implemented a risk register and booked a fire safety company to complete the remedial works required.

The practice provided evidence of annual portable appliance testing, and calibration of equipment. There was a log kept of daily vaccine fridge temperatures and a datalogger which provided continuous monitoring and alerts to temperature deviations, to ensure vaccines were stored within the recommended range but this was not being recorded consistently. However, It was not clear what the arrangement was for checking daily fridge temperatures when the responsible person was on leave. We saw no evidence the vaccine fridge temperatures had gone out of range.

The service had a business continuity plan which was regularly reviewed to manage major service disruptions. Staff reported no concerns regarding health and safety arrangements. Most staff had completed their mandatory fire safety training.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. The service had a recruitment policy and managers followed safe recruitment processes when employing staff in line with national legislation. This included identity checks, review of qualifications, obtaining professional references and a criminal records check. We saw the induction checklist was used during induction of new staff.

However, staff vaccinations were not always kept up to date in line with Green Book guidance and some staff immunisation records were incomplete. For example, a salaried GP had only partial records, with Hepatitis B and MMR documented but other routine vaccinations missing, for example tetanus, polio and diptheria and influenza. There was no Hepatitis B record or risk assessment for one non-clinical staff member, and no flu vaccination record for a practice nurse. Where staff declined to provide evidence, risk assessments had been completed. Following our assessment, managers confirmed that the salaried GP had provided proof of their routine immunisations. Leaders told us that following our assessment, they had completed risk assessments for affected staff, and offered Occupational Health meetings.

Leaders used an electronic management tool to monitor completion of mandatory staff training. Clinical and non-clinical staff had completed mandatory training and received an annual appraisal. Learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence. Where people had specialist needs, staff had received training on how to support autistic people and people with a learning disability. Clinical staff and non-medical prescribers had their patient consultation records regularly reviewed by the lead GP to ensure clinical competence and clinical supervision meetings were routinely documented.

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 observed that the facilities and premises were visibly clean, and systems were in place to prevent the spread of infection. Personal protective equipment (PPE) was well stocked and placed appropriately throughout the building. There was a dedicated lead for infection prevention and control. Staff had received training relevant to their roles.

Cleaning schedules were in place, and regular infection control and cleaning audits were conducted to maintain standards. Clinical waste, sharps, and clinical specimens were managed carefully to keep everyone safe.

However, staff vaccinations were not always kept up to date in line with the latest UK Health Security Agency (UKHSA) guidance. There was a clear system for reporting infection concerns to the relevant agencies, such as notifiable diseases.

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