St Peter's 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

Staff kept facilities clean and maintained equipment appropriately to ensure people were kept safe. They assessed and managed the risk of infection well and took steps to control the risk of it spreading. There were enough staff with the right skills, qualifications and experience. However, some staff were not fully compliant with the required recruitment checks and, there was not always a full immunisation history, or risk assessment, of staff vaccinations against potential healthcare acquired infections.

This service scored 72 (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 mostly detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The service was owned by the partners 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 risks. For example, fire safety and legionella. 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 had 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, nurses, receptionists and pharmacists. Leaders ensured staff were up to date with their training. However, we found not all staff including Primary Care Network (PCN) staff had completed their mandatory training at the time of the onsite inspection. The practice had completed a risk assessment and demonstrated an operated system of training reminders to prompt staff to complete outstanding mandatory training. Mandatory training compliance was monitored through regular practice meetings and reviewed as part of the annual appraisal process.

The service had not always followed safe recruitment procedures when employing staff, which was in line with national legislation. For example, physical and mental health information had not been recorded, the appropriate employment references were not contained within the staff records, in addition, 2 members of staff did not have their immunisation recorded. Evidence was provided to show that retrospective photo IDs and the immunisation history were completed immediately for a clinician following the assessment.

Staff told us they received regular appraisals and opportunities to discuss their learning and development needs. Additional training needs were identified, leaders supported staff to access appropriate training to develop their knowledge and skills and support them in carrying out their roles effectively.

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’s infection prevention and control (IPC) lead conducted monthly IPC risk assessments and audits to ensure compliance and took action where necessary to mitigate any identified risks. An action plan had been developed to capture areas that need to be addressed. During the inspection, we observed areas of exposed cracked plaster and staining to the ceiling following a previous roof leak. The practice agreed to include the identified environmental concerns within its environmental risk assessment to ensure the risks were assessed, monitored and actioned appropriately.

During our onsite visit, the service's premises and a sample of equipment reviewed was noted to be visibly clean.

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