The Victoria 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.

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

We found the monitoring of some medicines required strengthening to ensure all patients received the appropriate care and reviews. Following the assessment, we received assurances from the clinical leadership team that action was being taken to review all patients we had identified, and processes were being reviewed to ensure all patients received regular monitoring.

Systems were in place to protect individuals from abuse and avoidable harm. We found safeguarding procedures were in place and safety was clearly prioritised across the service.

Health and safety procedures were regularly monitored, and the premises were appropriately maintained. Any actions identified were acted on to reduce potential risks.

We found safety incidents were investigated, and there were processes to share learning to identify shortfalls and prevent recurrence. Regular practice meetings were in place where learning was shared with the practice team to mitigate any future risks.

This service scored 72 (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 learnt to continually identify and embed good practice.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. Representatives from the Patient Participation Group (PPG) felt the provider took concerns seriously and proactively made improvements to the service. Managers encouraged staff to raise concerns when things went wrong. The provider had processes for staff to report incidents, near misses and safety events. The practice had a significant events policy. Staff felt there was an open culture, and that safety was a top priority. Regular meetings were held to ensure learning was shared. These included daily huddles and weekly GP partner meetings.

There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Information reviewed demonstrated that people had opportunities to provide feedback, and they knew how to make a complaint. Lessons were learnt from individual complaints and shared with the practice team to improve the quality of care. Feedback and information were available in the practice and on their website.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Effective systems were in place for processing information relating to new people including the summarising of new records. We found clinicians made appropriate and timely referrals in line with protocols and up to date evidence-based guidance. This was supported by a system in place to ensure all patient information including laboratory test results and referrals were reviewed and actioned in a timely manner.

The provider told us that there were processes in place that was monitored and managed to keep people safe. For example, the provider was part of the primary care network (PCN) and attended regular meetings with other agencies across the locality to share and discuss information relating to patient care and treatment.

There were a range of structured meetings in place. These included safeguarding, multi-disciplinary and practice team meetings.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations.

There was a safeguarding lead for children and adults, and all staff were aware of who to speak to if they identified a safeguarding concern. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

There were processes in place to follow up children and young people who were not brought to their appointments with the provider and for secondary care appointments.

Safeguarding meetings were held regularly. Community teams were invited, and information was shared appropriately for the care of people with safeguarding and vulnerable concerns.

There was a policy in place for the renewal of DBS checks. Records we examined showed that all staff had a DBS check in place. DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable.

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.

Staff could recognise a deteriorating patient and knew of action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated. Emergency equipment was available and maintained. All staff were trained in basic life support.

Leaders told us that they worked with services locally to understand and manage risks. The practice also had registers in place to support those patients who were vulnerable or who had mobility or communication needs.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Health and safety related assessments and procedures to manage health and safety were in place. This included fire safety. Regular monitoring was in place to ensure guidelines were adhered to and all staff had been made aware of the appropriate procedures to follow.

Staff had been provided with training in health and safety related topics such as fire safety, infection control, basic life support and resuscitation training. Staff reported during discussions that they had no concerns regarding the arrangements in place to ensure health and safety.

There were policies and procedures in place for the management of health and safety. Fire safety policies were in place and staff were aware of how to access these. Fire marshals had undertaken additional training for the role. Systems were in place for the regular checks of fire alarms, extinguishers and fire evacuation procedures.

The practice had completed assessments in place for the control of hazardous substances. Evidence provided by the practice showed equipment was regularly calibrated and electrical items were PAT (portable appliance testing) tested in November 2024. Evidence provided showed the next testing had been booked for the forthcoming week.

There was a business continuity plan in place which was monitored and reviewed. Reception and administration staff who handled calls to the practice and arranged appointments with the clinical team were aware of potential red flag symptoms. Staff knew when to notify a GP or other clinicians with concerns about a patient who may be acutely unwell and/or deteriorating.

During our site visit we found the premises were well maintained. The provider detected and controlled potential risks in the environment. They made sure equipment, facilities and technology supported the delivery of safe care. Regular checks were carried out on the premises, facilities and the equipment provided. Contracts were in place to ensure the premises were clean and well maintained. Clear signage around the building supported people and staff in the event of an emergency evacuation.

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.

Evidence provided demonstrated systems were in place for the monitoring of staff. We found training was up to date, learning needs and development of staff was managed appropriately and staff were working within their agreed areas of competence. The practice had recruitment policies in place, and all staff had completed disclosure and barring checks. All newly employed staff had completed an induction to ensure they were competent in carrying out their role. We reviewed 4 personnel files and found appropriate checks such as previous employment record, immunisation status and proof of identity checks had been completed. Personnel folders were well organised and there was a systematic approach to ensure that personnel folders were managed appropriately.

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.

An infection control audit had been completed to identify potential risks and take appropriate action where required. The latest audit had been completed in February 2025, and the practice had achieved 98% overall. Monthly audits of the treatment room were completed where minor surgery had been performed.

The practice had a designated infection, prevention and control lead and all staff had completed training relevant to their role. Staff were aware of the systems and processes to follow to ensure clinical specimens were handled safely.

The practice had policies in place for infection, prevention and control which was accessible to staff and staff were aware of the action to take. For example, in the event of a sharps or contamination injury.

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.

The practice worked with the clinical pharmacists from the local Primary Care Network (PCN) to monitor people and the prescribing of medicines. We found medicine monitoring required further strengthening. A clinical search identified patients who were frail or aged 75 years and above who were on medicines called Direct oral anticoagulants (DOACs) which are used to help prevent blood clots from forming and had not had the appropriate monitoring in the last 4 months. We found 15 patients had not had the appropriate monitoring. We reviewed a random sample of 5 records and found all patients were overdue the recommended monitoring.

The provider was able to demonstrate they had some processes in place in relation to safety alerts issued by the Medicines and Healthcare products Regulatory Agency (MHRA), however further strengthening was required to ensure all alerts were acted on. We reviewed a safety alert concerning people 65 years and above who were on medicines call citalopram/escitalopram, used in the treatment of depression. We found 2 patients on these types of medicines. We reviewed both records and found no evidence that a discussion with the patient had been held concerning the potential risks, of these medicines. Following the onsite assessment, we received assurances that all the clinical searches we had undertaken had been reviewed and action had been taken to review each patient identified as requiring monitoring. We reviewed another safety alert for methotrexate that had been issued in 2020. We reviewed a random sample of 5 records and found 1 record required the day of the week to be added to ensure patients took the medication on the same day every week.

There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.

People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms. Staff received regular training, were competency assessed on medicines optimisation, and felt confident managing the storage, administration and recording of medicines. Staff managed prescription stationery appropriately and securely. Staff followed protocols to ensure they prescribed all medicines safely, and ensured people received all recommended medicines reviews and monitoring.

Medicines including controlled drugs were stored securely, however on reviewing the temperature recording of the vaccine fridges we found there were a range of days when temperature had not been checked. This posed a potential risk for the vaccines as they may have lost their effectiveness if they had become too hot or too cold at any time. Following the assessment, we received assurances that a named staff member for each day had been given responsibility for checking fridge temperatures and the practice had assured themselves there were no potential risks identified to the vaccines currently stored. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines, vaccines, and controlled drugs. Waste medicines were recorded and disposed of appropriately including medicines returned by patients. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments.

Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. Prescribing data reviewed as part of our assessment confirmed this. For example, the number of antimicrobials issued by the provider was lower than local and national averages. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.