The Bassingham 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 people were protected from abuse and avoidable harm. At our last assessment, we rated this key question as good. At this assessment, the rating remains the same.

This service scored 75 (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 potential risks in the care environment but some control measures in place for legionella were not being acted upon. They made sure equipment, facilities and technology supported the delivery of safe care.

The service had contracts to ensure the premises was maintained. Staff and leaders completed some 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 reviewed and outlined how the service should continue to operate in the event of a disruption.

We saw evidence that risk assessments had been undertaken by an external contractor in respect of fire and legionella. Actions identified by the risk assessments had been completed with the exception of an emergency plan relating to fire. We were shown the draft plan and told this was going to be finalised and displayed in the practice.

The legionella risk assessment identified the need to monitor water temperatures in the practice. While the temperatures were being monitored, we found that on occasion these were not within an appropriate range and no action had been taken to address this. Following our assessment, we were told of remedial actions taken to address the issues.

We saw there were COSHH risk assessments and safety data sheets relating to cleaning products provided by the contracted cleaning company, however there was limited information relating to other products being used in the practice, to identify, for example, how they could be hazardous and how they should be handled.

The service made sure there were enough qualified, skilled and experienced staff, who received support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The service employed a range of clinical and non-clinical roles, which included GPs, advanced nurse practitioners, practice nurses and health care assistants. They were also supported by a mental health practitioner, a health and wellbeing coach, a social prescriber, a physiotherapist, a clinical pharmacist and pharmacy technician, an occupational therapist and a care coordinator who were not directly employed by the practice.

Leaders ensured staff were up to date with their training which the service had deemed mandatory and operated within their agreed areas of competence. However, we found that only one member of staff had completed training relating to learning disability and autism. The Health and Care Act 2022 introduced a statutory requirement that CQC-registered providers must ensure their staff receive learning disability and autism trainingappropriate to their role.   

Staff were supported to develop and were positive about the training and development opportunities available. We found that staff had received regular appraisals with the exception of one staff member.

The service followed safe recruitment procedures when employing staff, which was in line with national legislation. This included identity checks, review of qualifications, obtaining of professional references and a criminal records check. However, the practice obtained a DBS at the point of employment for each staff member but were not able to evidence that they had considered if and when new checks were needed.

Processes had been established to ensure staff working for, but not directly employed by the practice, were recruited safely, had received appropriate and up to date training and were working within their agreed areas of competence.

We saw evidence that formal and informal clinical supervision was taking place and recorded appropriately. This included auditing the work of non-medical prescribers.

We saw the practice held relevant information relating to the immunisation status for staff.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service had cleaning schedules available, which outlined how staff should clean the building and its equipment. The service demonstrated how these were monitored and completed to maintain oversight of cleaning arrangements. During our onsite visit, the service's premises and a sample of equipment reviewed was noted to be visibly clean. The service’s infection prevention and control lead conducted regular risk assessments and audits to ensure compliance and took action where necessary to mitigate any identified risks and monitored outstanding actions. Staff had completed relevant training in infection prevention and control.

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