Norwood 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 inspection, we rated this key question as good. At this assessment, the rating remains the same.

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.

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.The premises had a number of new refurbishments in consultation rooms since the last assessment. The service had some health and safety assessments in place however, they did not have a full and comprehensive health and safety risk assessment carried out. We did not see (COSHH) Control of Substances Hazardous to Health risk assessments for the hazardous substances in use. The service had recently had a fire risk assessment which was forwarded to CQC following the assessment. The provider confirmed that all actions identified in the assessment would be completed as required.

The service had systems in place to test electrical equipment to ensure it was safe to use, contracts were in place for this and records we saw indicated the required electrical and health and safety checks were completed annually. There was a business continuity plan in place which was monitored and reviewed.

The service made sure there were enough qualified, skilled and experienced staff, who received support, supervision and development. They worked together well to provide safe care that met people’s individual needs. The service employed a range of clinical and non-clinical roles, which included GPs, advance nurse practitioners, practice nurses and reception and administration staff. The service also supported GP registrars and medical students in training. Leaders ensured staff were up to date with their training which the service had deemed mandatory and operated within their agreed areas of competence.

There were safe recruitment practices to make sure that all staff, including agency staff, were suitably experienced, competent and able to carry out their role. Processes were in place to ensure staff were fit to work at the service, for example Disclosure and Barring Service (DBS) checks for staff were completed. We reviewed a number of staff files and found there were gaps in the information held for some staff members, for example, vaccination records and photo identification. Following the assessment the provider contacted CQC to confirm that immediate actions were taken and this information was now in place for all staff employed at the service.

Systems were in place to ensure staff received good support, supervision and appraisals for their professional development. Staff confirmed they received training appropriate and relevant to their role. They told us they felt supported with their professional development and were given opportunities to learn.

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 provider carried out infection prevention and control (IPC) audits and took action where needed. The service had an IPC lead, and all staff completed mandatory IPC training. The service stocked sufficient personal protective equipment and positioned it appropriately throughout the premises. The service-maintained staff vaccinations in line with current UK Health Security Agency (UKHSA) guidance, where relevant to their roles. They also operated a system to report infection-related concerns, including notifiable diseases, to relevant agencies.

The service had cleaning schedules available, which outlined how staff should clean the building and its equipment. These were monitored by the management team to ensure effective oversight of cleaning arrangements. During our onsite visit, the service's premises and a sample of equipment reviewed was noted to be visibly clean. The service had arrangements for the collection, handling and testing of urine samples. External and bulk storage for clinical waste was not kept secure outside of the premises. Following the assessment the provider confirmed that new clinical waste bins had been ordered and they would ensure they were locked and kept in a secured area.

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