Cheddar Medical Centre

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 has changed to requires improvement.

This service scored 62 (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.

Staff and leaders completed health and safety risk assessments and undertook audits to ensure they had identified and addressed risk. However, during the onsite visit, it was noted actions to mitigate risks had not always been identified or taken place. For example, the service’s fire risk assessment referred to regular fire drills and staff being trained to use fire extinguishers, but the service was unable to provide evidence to demonstrate these actions had taken place. We were provided with evidence to show some staff had completed fire warden training, but their certificates indicated the training they had completed had expired. Annual testing of water for the presence of Legionella (a bacteria in water which can cause breathing problems) had taken place but there was no risk assessment which identified control measures to mitigate risks in line with guidance.

However, the service had contracts to ensure the premises was maintained.

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

Emergency medicines and equipment were stored centrally so staff could access it at any time.

The service did not consistently carry out all required pre-employment checks in line with national legislation. However, the service made sure there were enough qualified, skilled and experienced staff. They made sure staff received effective support, supervision and development.

The service did not always follow safe recruitment procedures when employing staff. During the onsite visit, we viewed 3 staff files and found each was missing pre-employment checks in line with national legislation. For example, 1 staff file we reviewed was missing proof of identity, evidence of satisfactory conduct in previous employment related to health and social care and evidence to show qualifications and professional registration had been checked prior to commencing employment.

We were told new employment checks were not carried out when members of staff were re-employed by the service, as they had previously worked for the service and leaders had no concerns about their conduct. However, no associated risk assessment had been undertaken to formalise this decision.

None of the staff files we viewed contained a pre-employment health check in line with national legislation. There was no evidence of gaps in employment history having been discussed in 2 of the files we viewed.

We asked to see the service’s recruitment policy and the service said they did not have one.

Following the onsite visit, the service immediately created a new recruitment policy which listed pre-employment checks in line with national legislation, that would be carried out for new starters.

Staff had a Disclosure and Barring Service (DBS) check carried out before employment commenced. (A DBS is a check which enables employers to check the criminal records of current and potential employees to ascertain whether they are suitable to work). The service was in the process of obtaining new DBS checks for all members of staff to ensure this is updated annually.

The service employed a range of clinical and non-clinical roles, which included GPs and nurses.

Leaders ensured staff were up-to-date with their training which the service had deemed mandatory and operated within their agreed areas of competence. Staff could access support and supervision during team meetings.

Leaders told us staff had access to occupational health and reasonable adjustments had been made to support staff to be at work.

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The service had cleaning schedules, which outlined how staff should clean the building and its equipment. The service demonstrated how these were monitored for completion to maintain oversight of cleaning arrangements. However, during the onsite visit, 1 of the 11 treatment rooms was noted to have a combination of carpet and hard flooring. This room was used to take blood and store specimens in a fridge. The service had not risk assessed the risk of having carpet in a room where there was a risk of bodily fluids being spilt. There was no mention of carpeted flooring in the IPC policy. Although the carpet was noted to be visibly clean, staff did not know when the carpet in this room was last cleaned or when it was next due to be cleaned. Following the onsite visit, the service provided evidence the carpet was last cleaned in January 2025. The service also confirmed the carpet was cleaned as of 19 June 2026 and will be scheduled to be cleaned every 3 months in the future based on their own assessment of risks identified.

Clinical waste was stored safely inside and outside of the premises. However, during the onsite visit, sharps bins used for the disposal of used needles, were not always labelled appropriately in line with policy. For example, out of the 5 sharps bins we viewed, 1 had not been labelled with any information to indicate when the sharps bin had been first used, and 2 were missing the name of the service. This had not been identified as an issue during the last IPC audit.

During our review of 3 staff files, only 1 of them contained evidence of all the routine immunisations and selected (if required) vaccines in line with national guidance. There were no records to indicate whether staff had declined vaccinations and what measures had been put into place to mitigate risk.

However, staff had completed relevant training in infection prevention and control.

During our onsite visit, we found the premises and a sample of equipment reviewed to be visibly clean.

The service’s infection prevention and control (IPC) leads conducted regular risk assessments of infection control processes, and audits to ensure compliance, and took action where necessary to mitigate any identified risks. The last IPC audit was carried out in May 2026 and although it mentioned carpet in 1 of the rooms, it did not mention a cleaning schedule and did not identify any issues with the labelling of sharps bins.

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