Shere Surgery/Dispensary

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 and controlled potential risks in the care environment. 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 health and safety risk assessments and undertook audits to ensure they had identified and addressed all risks. We found where mitigating actions were required action plans were not always reviewed or updated to demonstrate completion. However, we spot checked some of the actions and found that they had been completed. We found that in some cases where concerns were identified, such as water temperatures being out of the acceptable range, these were not raised to senior leaders in a timely manner, although once they were raised action was taken quickly. The service had a business continuity plan which was regularly and outlined how the service should continue to operate in the event of a disruption.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. We spoke with staff who told us how they had been supported to develop in their career within the practice. 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, nurses and dispensary staff. However, leaders could not demonstrate that all staff were up to date with their training which the service had deemed mandatory and operated within their agreed areas of competence. For example, the health and safety audit carried out by an external specialist company, in July 2025 identified there were no records of staff receiving appropriate health and safety training, particularly when starting employment. When we reviewed staff training records we found there were still gaps in health and safety training for a number of staff. For some staff there was no record of the training being completed and some who last completed training in 2022. We also found that the practice did not hold records of role specific training, such as cervical screening and immunisation. We were told they relied on the individual staff members to ensure that their training was up to date.

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.

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 for completion 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. Although we did note that the area around the door threshold of one clinical room required further cleaning. Most staff had completed relevant training in infection prevention and control (IPC), including additional training for the IPC lead.

The service’s IPC lead conducted regular risk assessments and audits to ensure compliance and took action where necessary to mitigate any identified risks. We saw evidence that a number of audits to support IPC had been carried out recently including hand hygiene, clinical waste, and sharps management. However not all audits were available, for example we were told that a comprehensive audit had been carried out earlier this year, January 2026, in line with the primary care cleanliness standards which had identified a number of required mitigating actions, but the practice were unable to produce this audit or resulting action plan.

We found that the practice did not hold any immunisations records for a member of staff who has been working clinically in the practice for a number of months, and there was no risk assessment in place. This meant the practice could not demonstrate that all staff were immunised in line with current Public Heath England guidance to ensure that employees and patients were protected.

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