Norton Canes Health Centre Also known as Dr W Nilar and Partner

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 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 was based within a health centre shared with 2 other independent GP Practices and a range of NHS community care services. The property was managed on behalf of the NHS by NHS Property Services, which served as the overarching landlord and head tenant for the facility.

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

Contracts were in place to ensure the premises was safe and maintained. During our site visit not all the relevant information was readily available from the management company, NHS Property Services but was later shared with us. This included confirmation that recommendations made in the fire risk assessment had been addressed in addition to a new gas safety record.

Fire safety drills had been completed, and a designated fire marshal was in place to manage emergencies. The premises were secure, with restricted access to staff offices. Staff and leaders completed health and safety risk assessments and undertook audits to ensure they had identified and addressed risks. 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.

The service had systems in place to monitor and track prescription stationery, however access to this stationary was not locked or restricted to key staff only. This compromised the security of blank prescriptions. Following our feedback, the provider told us they would take action to address these safety concerns.

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.

The service employed a small range of clinical and non-clinical roles, which included GPs, a practice manager, nurse and a small team of reception/administrative staff. In addition, the service utilised staff employed through their local Primary Care Network, providing a broader range of services to patients. This included a cancer care co-ordinator, social prescriber, mental health facilitator, paramedics and pharmacists.

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 told us they received support, supervision and learning and development opportunities. They said they worked well as a team to provide safe care that met people’s individual needs.

The service did not always follow safe recruitment procedures when employing staff, which were in line with national legislation. For example, obtaining full employment history, a criminal record check or completing a risk assessment prior to employment and staff immunisation history. Systems were in place to provide reassurance that staff employed by the Primary Care Network (PCN), and working in the practice, had been appropriately recruited, trained and supported.

The service had mainly assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. Staff had completed relevant training in infection prevention and control.

The practice had a designated infection prevention and control (IPC) lead. Discussions with them demonstrated they had a clear understanding of their role and responsibilities. They had carried out an IPC audit in December 2025 to ensure compliance. They told us they had previously taken action with the NHS Property Services to mitigate identified risks. For example, the use of non-foot operational waste bins in shared toilets. The lead told us an external independent IPC audit had been requested and was due to be carried out at the service shortly. A cleaning audit of the health centre had been carried out by NHS Property Services in May 2026 which showed an overall compliance score of 92%.

The service had cleaning schedules available, which outlined how staff should clean the building and its equipment. However, those sampled were not initialled or dated by the recorder. The service told us they would action this minor shortfall in addition to ensuring posters in clinical areas were wipeable and plants in rooms were added to the cleaning schedule.

During our onsite visit, the premises and a sample of equipment reviewed appeared clean and tidy and appropriate processes for the disposal of clinical waste were in place. We reviewed a sample of equipment and medical consumables which were found to be visibly clean and in date. However, we did observe a cleaning utility room in a non-patient area unlocked with cleaning products in and mops incorrectly stored. The practice took immediate action to address these concerns directly with NHS Property Services.

Patients we spoke with during our site visit told us they were satisfied with the cleanliness and hygiene standards of the practice.

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