The 157 Medical 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 staff protected people from avoidable harm and made sure care was delivered from environments that were clean and well maintained.

The practice did not consistently ensure a safe environment, with outstanding fire safety actions identified in the fire risk assessment. The practice did not demonstrate effective oversight of mandatory training or safe recruitment procedures. Infection prevention and control arrangements were not consistently effective, with limited oversight of cleaning standards.

This was a focused assessment, which meant we did not assess all quality statements. Our rating is determined from the findings of both this assessment and our previous assessment. At our last assessment, we rated this key question as good, and at this assessment, the rating remains the same. The updated quality statement scores have been issued where relevant.

This service scored 66 (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 practice did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. Although leaders had completed some actions identified in the fire risk assessment dated December 2025, several required actions remained outstanding. However, following the inspection, the practice took steps to address these concerns by contacting a qualified professional to obtain a quotation and planned the required actions.

The practice did not always have full control over systems for the safe and effective management of clinical waste. We also found the clinical waste bin stored outside of the building was not locked. The provider was aware of this issue and had been in contact with the waste contractor regarding the delivery of replacement bins. We saw email evidence of correspondence and escalation relating to the replacement of bins.

All consultation rooms were located on the ground floor, making them easily accessible. The practice had a portable ramp, automatic doors, and an accessible doorbell to support patients with mobility needs.

We saw evidence that the practice completed a legionella risk assessment and of sample analysis being completed. Health and safety risk assessments and audits had been undertaken, for example, for infection prevention and control (IPC) and non-medical prescribing.

The practice had a detailed business continuity plan which was regularly reviewed and which outlined how the practice should continue to operate in the event of a disruption.

The practice did not always make sure there were enough qualified, skilled and experienced staff. We identified gaps in the practice’s oversight of staff training. Staff were not always up-to-date with mandatory training. While we were informed that training was monitored at federation level and staff were notified when training was due, and provided with protected learning time, the practice did not demonstrate sufficient oversight or assurance to ensure training compliance was consistently maintained.

The practice employed a range of clinical and non-clinical roles, which included GPs, a practice nurse, advanced nurse practitioner, healthcare assistant and pharmacists.

Staff received regular annual appraisals to support their professional development and ensure high standards of care. Staff told us they felt supported and had access to advice, if needed. Leaders carried out clinical supervision to ensure staff were operating within their agreed areas of competence and to identify learning needs.

The practice did not always follow safe recruitment procedures when employing staff. The practice did not always carry out recruitment checks in accordance with relevant guidance and practice’s own policy. We reviewed 4 staff recruitment files and found that 2 contained only 1 reference. Evidence of qualification or professional registration was not always stored in staff recruitment files. Following the inspection, the practice sent us evidence of missing qualifications and professional registrations now being in place.

The practice organised annual face-to-face Basic Life Support training session for all staff.

The practice did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The practice did not have effective oversight of cleaning arrangements to ensure a consistently safe and hygienic environment. Although the practice had cleaning schedules in place and worked with external cleaning contractors, it did not demonstrate how it monitored these arrangements to maintain effective oversight. During the inspection, we observed dust on high-level surfaces in several clinical rooms. We also noted that a chair in the waiting room had a torn surface, which prevented thorough cleaning. We saw that clinical equipment was visibly clean, and staff told us they cleaned equipment after each use. Following the inspection, the practice acted quickly and took steps to address these issues with the cleaning contractor.

The practice carried out regular IPC risk assessment and audits. The practice had a designated IPC lead, and all staff received relevant training in IPC. Four out of 5 staff recruitment records showed that immunisations were up-to-date and appropriate to their roles.

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