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

This service scored 69 (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. However, it did not consistently detect and control potential risks in the care environment.

The service had contracts to ensure the premises was maintained. Staff and leaders completed health and safety risk assessments and undertook audits to identify and address risks. This included checks on equipment used.

There were effective arrangements for fire safety and clear signage to direct people to a safe place in the event of a fire. Fire equipment and systems had been serviced and maintained.

During our onsite visit at the branch site, we noted a medicine fridge had been moved to a new area due to approaching maximum safe storage temperature during a heat wave. However, the room door was noted to be open and did not have signage to indicate it was a staff only area to maintain secure storage. Additionally, the keys to lock the fridge were readily accessible. During our onsite visit, the staff immediately ensured the room would be locked for safe medicine storage.

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 made sure there were enough qualified staff, who received effective support and supervision. However, staff training records showed not all staff had received training in line with the service’s policy.

The service employed a range of clinical and non-clinical roles, which included GPs, nurses, dispensers and health care assistants. We reviewed training records and identified 10 administrative members of staff had not completed training in areas such as accessible information standard, basic life support and fire safety. The service told us that these were new members of staff. Following our onsite visit, the service sent evidence that showed timeframes for undertaking training and reviews to ensure training had been completed.

We reviewed 8 staff files during the onsite visit. There was no evidence of checks on professional qualifications on an ongoing basis in the clinical staff files that we reviewed. Some files did not have 2 references in line with the service’s recruitment checklist. The service told us they usually obtained 2 references related to previous employment, but we identified, there was only 1 reference available in some files. There was no clear protocol or evidence of documentation on the follow-up actions when only 1 reference could be obtained. After our onsite visit the service sent us evidence, they had taken action to rectify this. However, staff files did contain information on employment history and Disclosure and Barring Service (DBS) checks had been carried out. (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).

Staff operated in their agreed areas of competence. The service carried out learning events which included developing a frailty template to share information with other services and provided information on healthy living to people who used the service. Training had also been carried out on the triage system which had been recently introduced.

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.

During our onsite visit, we observed sharps bins were stacked on the floor, which was not in line with best practice guidance. In addition, we saw fabric privacy curtains in some clinical rooms, but there was no risk assessment to demonstrate how risks associated with these curtains had been mitigated. Cleaning schedules showed that the curtains were vacuumed on a daily basis, but they had not been cleaned by washing or dry cleaning to ensure infection risk was minimised. Following assessment, the service sent evidence to show that fabric curtains had been replaced with disposable curtains and sharps bins were stored appropriately.

The service told us the infection prevention and control (IPC) lead had oversight of regular risk assessments and audits which were conducted by the practice manager, to ensure compliance and took actions where necessary to mitigate identified risks. The practice manager had received training to carry out IPC audits.

Hand hygiene audits were undertaken for new members of staff; however, they were ineffective for the purpose of monitoring and ensuring continued compliance. The service was unable to demonstrate records of compliance checks despite confirming these were undertaken. After our site visit the service provided evidence to show that going forward all staff would undertake an annual hand hygiene assessment and this would be recorded.

Cleaning schedules were in place and the service demonstrated overall how these were monitored. However, during the onsite visit, we identified equipment that posed an infection control risk, for example fabric covered chairs. Cleaning schedules included the cleaning of these. There was a plan to replace fabric chairs. However, wooden chairs in use had not been identified as a risk in the provider’s audit as they could not be adequately cleaned. Staff stated these would be reviewed and replaced. Following assessment, we were provided with photographic evidence to show replacement chairs had been purchased and were in use.

All staff had completed IPC training. All clinical rooms which were in use had adequate supplies of equipment and were notably clean and suitably maintained. There were supplies of personal protective equipment, such as gloves and masks. Information on infection control processes was readily available and clinical and domestic waste was appropriately segregated. The service had an external clinical waste bin which had not been securely stored in line with national guidance. We raised this with the service at the time of our visit, who took immediate action.

We requested a copy of the service’s annual infection control statement (a mandatory compliance document required under the Health and Social Care Act 2008 to ensure compliance with IPC practices). This was received, dated 6 July 2026 and covered the areas set out in best practice guidance.

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