Cheriton Bishop & Teign Valley Practice

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.

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.

The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff understood how to raise concerns and report incidents. Staff told us there was an open culture, and safety was a top priority. The service had processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints and incidents. The service managed complaints and incidents in line with their policies. When things went wrong, staff apologised and gave people support. The service held regular meetings to discuss complaints and significant events. Meeting notes were shared with all staff, including those who could not attend. Learning was shared and improvement was implemented to enhance people’s care. For example, the service monitored the trends of significant events and noted multiple incidents related to clinical or administrative information added to the wrong clinical records due to people sharing the same name. The service identified the people affected and applied a same-name pop-up alert as a reminder for staff. The service conducted an audit cycle from April to September 2025 and demonstrated sustained improvement after the measure, with no further incidents related to same-name patients at the end of the audit.

The service 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 systems for processing information relating to new patients. The service conducted regular audits to review the quality of summarising clinical records. Staff had clear responsibilities and followed systems to ensure continuity of care between secondary and primary care. Test results, referrals and clinical correspondence were managed in a timely manner, with cover arrangements during staff absences. Administrative staff were responsible for managing and monitoring referrals to ensure people were referred to other services appropriately and were prioritised for urgent actions.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

The service had effective systems and processes to keep people safe and safeguarded from abuse. Alerts on clinical records flagged people with safeguarding concerns, including their household members.

The service had safeguarding policies for children and adults which were accessible to all staff. The policies contained detailed internal safeguarding processes, safeguarding training requirements and contact details of local safeguarding teams.

All staff had completed mandatory safeguarding adults and children training at the appropriate level for their roles. In addition, the safeguarding leads provided in-house in-person safeguarding training and practised group exercise with all staff to enhance their knowledge and skills to identify and highlight safeguarding concerns. Staff knew who the safeguarding leads were. They could explain safeguarding processes and felt confident in raising concerns. The service maintained lists of vulnerable children and adults which were regularly reviewed at multi-disciplinary team meetings with external partners such as district nurses and social workers.

The safeguarding leads regularly attended safeguarding forums organised by the local Integrated Care Board (ICB) to keep up-to-date with safeguarding processes. (An ICB is an NHS organisation responsible for planning and funding services for their local population.)

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff could recognise a deteriorating person and knew what actions to take. Staff could summon help quickly in an emergency using the emergency button on the computer system.

The service had a medical emergency procedure which covered staff roles and responsibilities in the event of a person’s condition deteriorating. The service discussed various emergency scenarios with all staff during a training event to familiarise them with the actions needed. The service held appropriate emergency medicines and equipment with regular checks at both sites. Leaders had risk assessed which emergency medicines were required in the service and ensured these medicines were appropriately stocked and checked regularly.

People received advice on risks related to their condition and the actions to take if their condition deteriorated.

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

Health and safety and fire risk assessments had been undertaken and risks identified had been addressed. Fire equipment checks were documented. Electrical equipment was tested to ensure it was safe to use and the equipment was calibrated for accuracy.

The service had a health and safety policy and a business continuity plan detailing what actions to take in the event of an incident which would affect the running of the service. There was a lone working policy and risk assessment to promote staff safety.

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.

There was a range of clinical and non-clinical roles in the service. Staff said there were enough staff to provide safe and high-quality care.

Safe recruitment practices were followed. We reviewed staff files which contained all relevant information as required in the regulations.

Staff received an induction appropriate for their roles. There was a process to monitor training compliance, and all staff were up-to-date with their mandatory training.

Staff had regular appraisals to discuss their performance and learning needs. Staff were upskilled to support the service and their professional development. For example, the service provided protected time to support a staff member in pursuing training as a nursing associate.

There was established documented clinical supervision for the clinical pharmacist and advanced clinical practitioner but structured clinical supervision for the other clinical staff was only recently implemented. The process had to be further embedded.

All health coordinators were trained on administrative tasks and followed a competency handbook so that they could cover for each other during absences. However, there was no documented evidence of a clinical competency check for clinical staff, although the service explained they received direct observation during the initial phase of acquiring new skills before working independently. Following the assessment, the service developed a role-specific competency checklist for clinical staff to formalise the process. We did not identify any concerns related to staff competency.

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

During the site visit, we saw the premises were visibly clean and tidy. The service had a designated IPC lead. All staff had received relevant IPC training in line with their roles and responsibilities.

Up-to-date IPC audits were completed, and actions were taken to mitigate risks. Personal protective equipment (PPE) was available to staff. Sharps waste bins used for disposing of used medical instruments such as needles or syringes were safely managed. Clinical waste bins were locked and secured to avoid unauthorised use or removal.

Before our assessment, the service identified concerns in the cleaning standards of the previous cleaning contractor and changed to the current cleaning company in early March 2026. Floors of consulting rooms included both hard surfaces and carpeted areas, which presented potential infection control risks. Soft-furnished chairs were also present in the waiting areas at both sites. These issues were considered in the service’s most recent infection prevention and control (IPC) risk assessment in February 2026. The IPC policy outlined the actions required if carpets or soft furnishings became contaminated by spillages or body fluids. However, during the site visit, we viewed the cleaning schedule for both sites, which did not include cleaning of carpeted areas or soft‑furnished chairs, despite these being required under the IPC policy, risk assessment and new cleaning contract. At the time of the site visit, there was also no evidence of oversight of the cleaning schedule by the external cleaning company or monitoring of their overall cleaning performance.

Following the assessment, the service developed a standard operating procedure that set out cleaning frequencies for all areas, including carpeted areas, established regular communication with the cleaning company, and submitted evidence on monthly audits of cleaning performance. The service also replaced the soft furnishing chairs by wipeable vinyl bench at the main site.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

Blank prescription stationery was securely stored and accessible only to authorised staff.

The service had a process for authorising staff to administer medicines including Patient Group Directions (PGDs) or Patient Specific Directions (PSDs). (PGDs are a written instruction for the supply and/or administration of a named licensed medicine for a defined clinical condition. PSDs are a written instruction from a doctor or other independent prescriber for a medicine to be supplied or administered to a named person.)

The service had policies and procedures for the management of medicines. There were suitable processes for staff to follow when dispensing, ordering and disposing of medicines. including those needing cold storage and for controlled drugs.

The dispensary could arrange for some people to collect their prescriptions from a branch surgery or local drop-off point. This was operated under suitable processes and procedures, and records were kept.

The service stored medical gases, such as oxygen, safely and completed required safety risk assessments. The service had effective systems to manage and respond to safety alerts and medicine recalls.

Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes. For example, the service regularly monitored their prescribing practice and conducted multiple prescribing audits throughout the year. Prescribing data reviewed as part of our assessment confirmed this. For example, the service’s prescribing of gabapentinoids (medicines prescribed for treatment of epilepsy, neuropathic pain or generalised anxiety disorder but with risk of misuse or dependence) was below the national average.

As part of our inspection, a number of set clinical record searches were undertaken remotely by a CQC GP specialist advisor. We sampled 5 clinical records to look at the quality of medicine reviews and found all of them were reviewed appropriately. People who were prescribed high-risk medicines were monitored appropriately.

The service had recently implemented audits for non-medical prescribers (NMPs are healthcare professionals who can prescribe medicines but are not GPs). This was to ensure medicines prescribed were necessary, correctly prescribed and followed up when needed. The process had yet to be fully embedded into routine practice.