Spital 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 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 premises had a number of new refurbishments and building extensions since the last assessment. The service had health and safety and fire risk assessments in place to evaluate, address, and monitor any safety concerns related to the premises.An updated fire action plan showing the works to be completed, for example fire door repairs, was sent following the site visit. The service had systems in place to test electrical equipment to ensure it was safe to use, contracts were in place for this and records we saw indicated the required electrical and health and safety checks were completed annually. There was a business continuity plan in place which was monitored and reviewed.

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.

The service employed a range of clinical and non-clinical roles, which included GPs, and practice nurses. The service also supported GP registrars and medical students in training. Leaders ensured staff were up to date with their training which the service had deemed mandatory and operated within their agreed areas of competence. A number of staff had not completed mandatory update training at the time of assessment, but arrangements were in place to support this.

There were safe recruitment practices to make sure that all staff, including agency staff, were suitably experienced, competent and able to carry out their role. Processes were in place to ensure staff were fit to work at the service, for example Disclosure and Barring Service (DBS) checks for staff were completed. Systems were in place to ensure staff received good support, supervision and appraisals for their professional development. Staff confirmed they received training appropriate and relevant to their role. They told us they felt supported with their professional development and were given opportunities to learn.

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 provider carried out infection prevention and control (IPC) audits and took action where needed. The last external audit was carried out in February 2026 with a small number of improvements identified.

The service had cleaning schedules available, which outlined how staff should clean the building and its equipment. These were monitored by the management team to ensure effective 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 had arrangements for the collection, handling and testing of urine samples.

The service had an IPC lead, and all staff completed mandatory IPC training. The service stocked sufficient personal protective equipment and positioned it appropriately throughout the premises.

The service-maintained staff vaccinations in line with current UK Health Security Agency (UKHSA) guidance, where relevant to their roles. They also operated a system to report infection-related concerns, including notifiable diseases, to relevant agencies.

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