The Pines 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. The practice had established systems to assess, monitor and continue to improve the quality and safety of service. There was strong evidence to support a good learning culture and people could raise concerns. Managers investigated incidents thoroughly. People were protected and kept safe. The facilities and equipment met the needs of people, were clean and well-maintained. Systems for infection prevention and control (IPC) management were exemplary. There were enough clinical staff with the right skills, qualifications and experience. Managers made sure staff received regular appraisals. There was a system to oversee mandatory training which was monitored to encourage completion. There were processes for monitoring patients’ health in relation to the use of medicines, including medicines that require regular reviews. This key question has been rated as good.

This service scored 78 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice had a strong proactive and positive culture of safety, based on openness and complete honesty. Reporting forms were used and there was evidence these were investigated thoroughly. Themes were identified and lessons were learnt to continually identify and embed good practice. They actively listened to concerns about safety and thoroughly investigated and reported safety events. The practice maintained a significant event tracker and each event was risk rated using a RAG rating system to support effective risk management and reduce the risk of recurrence. (RAG rating stands for Red, Amber, Green and is a visual system used to indicate project or performance status, where red signals serious issues, amber indicates potential concerns and green shows everything is on track). Staff felt there was an open culture, and that safety was a top priority.

There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Learning from incidents and complaints resulted in changes that improved care for others. Representatives from the patient participation group (PPG) felt the practice listened to their feedback and took appropriate action to make improvements where possible.

The practice 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. There were effective systems in place for processing information relating to new patients. Leaders advised there were dedicated staff to support timely registrations and review of new patient records to ensure clinical staff had up to date knowledge when reviewing patients. The service worked with other providers to deliver shared care and when patients moved between services. There were systems in place for managing incoming correspondence for patients’ medical records. Referrals and test results were managed in a timely way.

The practice worked well with people and healthcare partners to fully understand what being safe meant to them and the best way to achieve that. They had a clear focus on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They always shared concerns quickly and appropriately. There was a safeguarding team, comprising clinical and non-clinical leads supported by a safeguarding administrator, with recruitment underway for a second safeguarding administrator. Staff were aware of who the safeguarding leads were. The practice maintained oversight of lists of vulnerable people which were reviewed regularly. Vulnerable people were coded on the system and had alerts added to their records.

Staff knew how to identify, report and act when dealing with safeguarding concerns. They worked well with other healthcare professionals to ensure the concerns were addressed appropriately. An effective system was in place for the management, oversight and reviewing of safeguarding concerns. Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. Safeguarding meetings were held routinely, and regular communication was maintained in between meetings. The practice acted on concerns and worked in partnership with other organisations. For example, they followed up children who attended AE and those that failed to attend their appointments. We saw there was extensive safeguarding support information displayed throughout the practice for both staff and patients, including information on domestic violence support available discreetly inside the toilets.

Staff worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs which was safe, supportive, and enabled people to do the things which mattered to them. Emergency equipment was available and maintained. The service managed significant events effectively. For example, leaders advised that following a significant event involving a very ill patient in the waiting room, staff were reminded of protocols and received appropriate support and training to reduce the risk of recurrence. 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.

The practice was fully aware of potential risks in the care environment and controlled them well. They made sure equipment, facilities and technology supported the delivery of safe care. Portable appliance testing and calibrations were completed. There was a business continuity plan in place which was monitored and reviewed. Contracts were in place to ensure the premises were maintained. Health and safety risk assessments and audits had been undertaken and risks identified had been addressed. Systems were in place to check safety equipment including fire alarms and emergency lighting. Fire evacuation drills had been completed. We observed fire exits were clear and fire safety equipment was easily available and regularly checked. Staff were aware of what to do in an emergency and where emergency medicines and equipment were stored. Allocated staff knew how to safely manage spillages of bodily fluids, with specialist kits readily available for use.

Leaders made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked collaboratively to provide safe care that met people’s individual needs. The practice employed non-medical prescribers and had established formal processes in place to monitor and audit their clinical practice. This formal process included audits of their prescribing practice, regular appraisals, feedback and support. A sample of staff files we reviewed showed staff were suitably qualified, maintained their professional registrations and their continuing professional development (CPD) and had up-to-date specialist training appropriate to their role. All staff had appraisals, access to regular clinical supervision and protected time to complete their mandatory training. Leaders maintained effective oversight of professional staff registrations and staff completion of training. During our assessment, we found the majority of staff were up to date with their training. Those outstanding some modules included new staff still undertaking their induction and staff away from work at the time of assessment. We reviewed evidence that demonstrated safe recruitment practices were followed.

The provider had appointed leads for the management of infection prevention and control (IPC). We saw evidence these leaders thoroughly assessed and managed the risk of infection. They always quickly detected and controlled the risk of it spreading and consistently shared concerns with appropriate agencies promptly. The practice team demonstrated an exceptional and sustained commitment to IPC, with evidence that this was fully embedded across the organisation rather than being a compliance exercise. Leaders had invested in high-quality external IPC training over consecutive years and had ensured that learning was systematically translated into day-to-day practice.

Staff were able to clearly articulate the principles of IPC and demonstrate how these standards had been implemented and maintained over several years. There was strong evidence that learning had been embedded into clinical practice through comprehensive policies, robust governance arrangements and a programme of regular environmental, hand hygiene and infection prevention audits. Audit findings were reviewed, acted upon and used to drive continuous improvement.

The provider had adopted a structured, evidence-based approach to IPC, making effective use of recognised resources and quality improvement tools to support high standards. This resulted in a culture where IPC was consistently prioritised, understood by staff and evident in everyday practice.

Although many of these elements reflect expected standards, the provider distinguished itself through the depth, consistency and sustainability of its approach. Rather than simply meeting regulatory requirements, they demonstrated a proactive culture of continuous learning and quality improvement, providing assurance that exceptionally high standards of IPC were embedded throughout the service.

We noted the premises were visibly clean and extremely well maintained on the day of our assessment. There was evidence of contingency planning to ensure IPC standards were maintained; with recently appointed staff also due to complete the same external training programme before joining the IPC leadership team.

During our previous assessment, in January 2024, we found there were gaps in the review of patients who were prescribed medicines that required monitoring. As part of this assessment, a GP specialist advisor undertook a series of patient clinical record searches, to assess whether clinicians were prescribing a range of medicines safely and whether patients were being reviewed in line with national guidelines. The results of our searches were positive.

We reviewed patients prescribed a disease-modifying antirheumatic drug (DMARD) used to treat rheumatoid arthritis and other inflammatory conditions by suppressing the immune system and reducing inflammation. The search identified 33 patients, all of whom had received the required monitoring.

We reviewed patients prescribed antiarrhythmic medication used to treat life-threatening heart rhythm disorders, particularly ventricular arrhythmias. Our search identified 7 patients, all of whom were receiving appropriate monitoring.

There was a process in place for recording and sharing Medicines and Healthcare Products Regulatory Agency (MHRA) safety alerts. Safety alerts were discussed in clinical meetings. Our clinical record review highlighted that safety alerts were actioned in line with guidance. Specifically, we reviewed patients prescribed a combination of medicines used to support patients with heart failure, to check they had received appropriate monitoring as required. Our search identified 49 patients with 4 who were potentially overdue their monitoring. We reviewed records for all 4 and found that all 4 were only slightly overdue. 1 patient had received their monitoring the day of our review, 2 were booked to attend that week and 1 had an appointment booked within 2 weeks of our assessment.

We reviewed patients potentially at risk of having a missed diagnosis of diabetes. Our search identified 45 patients potentially at risk. However, a review of 5 of these patients found none were at risk.

Our searches identified a total of 1,069 medication reviews that had been completed for patients in last 3 months. We reviewed a random sample of 5 of these medication reviews and found that all reviews had been completed appropriately.

We reviewed the prescribing of a medicine used to treat osteoporosis, Paget's disease, and conditions that cause high blood calcium levels, helping to strengthen bones and reduce fracture risk, to check that patients had been reviewed as recommended. Our search identified 39 patients prescribed this medicine. We reviewed a random sample of 5 of these patients and found no concerns with their care.

The practice adhered to an antibiotic stewardship policy that measures the appropriate use of antibiotics and optimises the use of antibiotics to improve patient outcomes. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment. 

Staff regularly checked medicine stock levels and expiry dates, including emergency medicines and vaccines. Medical gases such as oxygen were stored safely. Fridge temperatures were monitored daily, and staff knew what action to take if the temperature was out of range. Similarly room temperatures where medicines were stored were monitored for safety. Staff managed prescription stationery appropriately and securely.