Cranleigh Gardens 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.

The service was in breach of legal regulation in relation to safe care and treatment.

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 all risks. However, they did not always ensure actions identified through these processes were completed or recorded. This meant leaders could not always assure themselves that risks linked to water safety and fire were being effectively managed.

At Cranleigh Gardens Medical Centre (main site), we found gaps in records demonstrating water temperatures had been monitored and actions taken in accordance with the Legionella risk assessment (Legionella is a bacteria in water which can cause breathing problems).

At Westonzoyland Surgery (branch site), the Legionella risk assessment identified hot water temperatures did not reach 50 degrees, increasing the risk of this bacteria growing. It recommended, as a matter of urgency, that associated thermostats should be increased to ensure water temperatures reached at least 55 degrees. We did not see evidence this action had been completed.

Following the onsite visit, the service told us it had taken action and scheduled some actions identified in the risk assessments, including an annual flush of the hot water generator for both sites, due to take place in August 2026.

A fire risk assessment completed at the main site in July 2026 identified 2 actions, which the service already had either addressed or had plans to address. For example, they told us they had plans to relocate the fire evacuation assembly point further away from the premises as recommended in the risk assessment.

The branch site fire risk assessment, completed in June 2026, identified 32 actions to improve fire safety, 4 of which were assessed as high severity. For example, it identified that final exit doors on escape routes should be modified because they required keys to open them, which could delay evacuation in an emergency. We were not assured this was being addressed.

The assessment also identified trailing leads, overloaded sockets and inconsistent portable appliance testing. During the onsite visit, plug sockets remained overloaded. The service told us work had been scheduled to install more sockets.

An electrical safety inspection completed at the main site in March 2025 found the premises’ electrical installation was unsatisfactory. The report stated the recommendations did not adversely affect electrical safety but identified 1 urgent remedial action and 14 remedial improvements. During the onsite visit, we did not see evidence these actions had been completed. Following the onsite visit, the service told us it had spoken to an electrician who confirmed the urgent remedial action had been completed and that work had been undertaken on some of the remedial improvements.

An electrical safety inspection was completed for the branch site in July 2026 after the service identified it had not been undertaken within the previous 5 years, in line with guidance. The report deemed the electrical installation as satisfactory.

However, the service had contracts to ensure the premises were maintained. There was a business continuity plan, which was regularly reviewed and outlined how the service would continue to operate in the event of disruption.

The service had systems and processes in place to ensure there were enough qualified, skilled and experienced staff. However, they were not always effective. The service did not complete all required pre-employment checks in line with regulations and could not demonstrate staff received effective support, supervision and development.

During the onsite visit, we reviewed 4 staff files and found none contained all the pre-employment checks required by regulation. For example, all 4 files were missing evidence of a pre-employment health check and 2 were missing evidence that gaps in employment history had been explored. However, the service had recently reviewed its safe recruitment procedures for future staff. These included identity checks, verification of qualifications, obtaining professional references and a criminal records check.

Leaders told us staff completed an induction when they commenced employment, worked within their agreed areas of competence and received regular supervision and annual appraisals. However, during the onsite visit, we were unable to review most of these records because they were not held centrally. There was no central process to ensure these activities had taken place, issues had been identified or action had been taken where necessary. Leaders told us they had recently reviewed their induction policy, and inductions for future staff would be documented in staff files.

The service had a programme of mandatory training for staff. We reviewed training records for 3 members of staff and found gaps in completion of this training or training had not been completed at the frequency required. For example, training in significant events, moving and handling, duty of candour and conflict resolution had not been assigned or completed by these staff members. Following the onsite visit, we were sent evidence that some of these courses had been assigned to 2 staff members. However, this did not include all training the service identified as mandatory. The third staff member had recently started employment and was still completing their mandatory training.

The service employed a range of clinical and non-clinical roles who worked together to provide safe care that met people’s individual needs.

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

During the onsite visit, the premises and a sample of equipment reviewed were visibly clean. The service’s infection prevention and control (IPC) lead carried out regular risk assessments and audits to monitor compliance and took action where necessary to mitigate identified risks. The most recent IPC audit, completed in September 2025, identified concerns and action was taken. For example, some clinical rooms were cluttered with non-essential items and equipment, affecting the ability to clean the environment effectively. The service took action by emailing staff to remind them to keep areas free of unnecessary items. However, during the onsite visit, we found 1 room remained cluttered with non-essential items.

IPC training was mandatory for all staff, with the level and frequency dependent on their role. We reviewed 3 staff files and found 2 staff had completed appropriate IPC training. However, 1 staff member’s training record indicated they last completed this training in 2023, despite the list of mandatory training stating it should be completed annually. Following the onsite visit, we were sent evidence that mandatory training courses had been assigned to this member of staff, but this did not include IPC training.

Our review of 4 staff files identified there was no process to obtain evidence of vaccination history in line with national guidance. Staff were asked to complete a self-declaration form. However, this did not provide evidence vaccinations had been received and did not include all recommended routine vaccinations. There were also no records to indicate whether staff had declined vaccinations or what measures had been implemented to mitigate associated risks. Following the onsite visit, the service took action to request this evidence from all staff.

However, clinical waste was managed appropriately. The service had cleaning schedules in place, which outlined how staff should clean the premises and equipment. These schedules had been updated and implemented the week before the onsite visit. Staff told us how completion of the schedules would be monitored to maintain oversight of cleaning arrangements.

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