Whiteparish 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 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.

The service had not always effectively identified, monitored and mitigated risks relating to fire safety and health and safety. Actions identified in the most recent fire risk assessment, completed in 2024, remained outstanding despite the assessment recommending completion within 3 months. Although completion dates had been recorded against these actions, inspector checks undertaken during the onsite inspection indicated that some had not been completed. Service leaders confirmed that internal fire reviews had been undertaken; however, the individual completing these reviews had not undertaken the training recommended by the external provider to be deemed competent to carry out this role.

The service was unable to provide the emergency lighting certificate, which was due for renewal in June 2026. Service leaders advised that a previous booking for the fire alarm service and emergency lighting checks had been cancelled by the external provider. When the work was subsequently rebooked, the fire alarm service was completed, but the emergency lighting check was not undertaken. Records held by both the service and the external provider incorrectly indicated that the emergency lighting check had been completed.

Following feedback, service leaders advised that the emergency lighting check and a new fire risk assessment had both been booked to take place during the same week. The service had also updated its monitoring system to ensure fire alarm servicing and emergency lighting checks were recorded separately to improve oversight and reduce the risk of future omissions.

The service had enough experienced staff who received effective support and development, however, supervision and training records were not available to demonstrate that these had been taking place consistently. Staff worked collaboratively across roles to deliver safe, coordinated care that reflected people’s individual needs.

When the staff training matrix was submitted before the onsite inspection, we identified that some training required by the provider had not been completed within the required timescales. The service was not always able to demonstrate effective oversight of staff training, as some training records were not included within the central training system. Whilst all staff received annual appraisals, there was no formal documented clinical supervision process in place for non-medical prescribers, and non-medical prescribing audits were not being undertaken. Service leaders advised that informal clinical supervision arrangements were in place, including case-based discussions, supervisory observations and access to support from the duty doctor when required. However, they were unable to provide evidence of a formalised and documented clinical supervision process.

During the assessment, service leaders provided additional evidence relating to staff training and advised that outstanding training had since been completed or scheduled. An updated training matrix was submitted, and the service had developed a Training Handbook and Policy before we visited. In response to our findings, the service introduced a non-medical prescribing policy, implemented audit arrangements to strengthen oversight of prescribing practice, introduced an audit template, and provided examples of audits completed in the week following the onsite visit. Service leaders also advised that they would strengthen arrangements for clinical supervision through the implementation of a formal process and supporting policy.

The service employed a range of clinical and non-clinical staff, including GPs, nurses, paramedics, pharmacists and dispensers. The service followed safe recruitment procedures when employing staff, which were in line with national legislation. A review of 4 staff files confirmed appropriate recruitment checks had been completed and records were maintained accurately. This included identity checks, verification of qualifications, professional references and criminal records checks. Staff received a structured induction tailored to their specific roles and responsibilities, which included opportunities to shadow colleagues and meet with service leaders.

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 had infection prevention and control (IPC) processes in place, supported by relevant risk assessments, policies and audits. An IPC policy was in place, and the IPC lead undertook regular audits and risk assessments to identify and mitigate risks. Evidence of handwashing training was available, and hand hygiene audits were undertaken regularly. This included the use of a solution, which highlights areas missed during handwashing under a blue light, enabling staff to assess and improve hand hygiene technique. A follow-up service audit demonstrated that 28 staff members had successfully completed the assessment.

Vaccine fridges were functioning appropriately, with minimum and maximum temperatures recorded daily and no concerns identified within the documentation reviewed. Carpet cleaning schedules were available. During the inspection, the practice environment and a sample of equipment reviewed appeared visibly clean and tidy.

However, the service was not always able to demonstrate effective oversight of all IPC arrangements. Cleaning schedules completed by the external cleaning provider were not available, which meant the service could not demonstrate what areas had been cleaned or the frequency of cleaning activities. Although Control of Substances Hazardous to Health (COSHH) assessments were available for products used by the service, assessments were not available for products used by the external cleaning provider. Material Safety Data Sheets were available, but not for the products being used. Disposable mops were in use and used mop heads were observed hanging up to dry; however, the service was unable to locate any clean, replaceable mop heads at the time of the inspection. Appropriate COSHH signage was also not displayed on the COSHH cupboard at the time of the inspection. Following feedback, service leaders advised that replacement COSHH cupboard signage had been ordered. The provider confirmed that a meeting was scheduled with the external cleaning provider to review cleaning arrangements and strengthen oversight of cleaning activities.

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