Porters Avenue Doctors 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 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.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. Staff were able to use an in-house online portal to report any concerns. Leaders promoted openness and staff felt confident speaking up when things went wrong. Processes were in place for staff to report incidents, near misses and safety events which included, for example, a significant events policy and significant events log. The service had an electronic document management system where they could record and investigate complaints. Learning from incidents and complaints were shared in team meetings and resulted in changes that improved care for others.

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.

When transitioning to another GP, service user records were transferred via an electronic system. There were systems in place for processing information relating to new patients; to ensure information is received from the previous GP and undergoing a new patient health check for new service users. The service worked with other providers to deliver shared care and when patients moved between services. Referrals and test results were managed in a timely way.

Staff monitored the system to ensure referrals to specialist services were accurately documented, included the correct information, and were processed without delay. Safety netting procedures were in place to ensure all patients were appropriately followed up. Routine referrals were monitored to confirm whether patients still required specialist input or if their condition had deteriorated.

The service valued safeguarding, acted when necessary and had adequate policies and safeguarding registers in place to protect individuals from abuse and neglect. The service worked in collaboration with healthcare partners to ensure safeguarding cases and procedures were managed effectively. Safeguarding leads were involved in meetings held with multi-disciplinary staff where safeguarding cases were discussed.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. All staff members we spoke with were able to identify their safeguarding leads and how to escalate safeguarding concerns. The service maintained a list of vulnerable people and acted on concerns by working in partnership with other organisations.

The service maintained a safeguarding register which was updated regularly.

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.

Emergency equipment was available and maintained. Staff could recognise a deteriorating patient, including symptoms of sepsis, and knew of action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

During our site visit, we observed the premises of both practice sites. We found the premises were clean, well-maintained and safe for patient and staff use. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Contracts were in place to ensure the premises were maintained. Risk assessments and audits, including fire safety and legionella, had been undertaken and risks identified had been addressed. There was a business continuity plan in place which was monitored and reviewed, which addressed risks such as an IT failure or flooding; this was maintained across both sites.

The service made sure there were enough qualified, skilled and experienced staff who worked across both sites. They received effective support, supervision and development. Consultations were routinely audited in which a patient’s history, examination, plan, prescribing, safety netting and coding was looked at. The service submitted data to show that between May 2025 to June 2025, 208 consultation audits were carried out. Leaders held supervisory roles to guide and audit clinical staff members. They worked together well to provide safe care that met people’s individual needs.

There were a range of clinical and non-clinical roles within the practice. We found learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence. The service had an HR department responsible for undertaking recruitment checks. We reviewed a sample of recruitment records and found that staff were recruited safely with appropriate procedures being followed, such as DBS checks and the collection of references. However, the service could not locate induction documentation for one member of staff, citing they had transferred from paper to electronic records.

Relevant training for most staff was completed; we found Mental Capacity Act training for one staff member was incomplete when we reviewed their training but was completed immediately after the assessment.

The service assessed and managed the risk of infection. Premises across both sites were clean and well-equipped to support effective infection prevention and control. However, we found damaged floor seals in one of the clinical rooms as well as incorrect waste in the bins of a clinical room at the branch site.

The practice had a designated infection, prevention and control lead across both sites, as well as an organisation lead who conducted annual audits. Cleaning schedules were in place and followed. Training for relevant staff was completed. Risk assessments and audits were regularly performed, and actions were taken to mitigate risks. For example, damaged fabric chairs in one of the clinical rooms were removed as a result of an infection prevention and control audit.

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.

Our review of records showed that people taking medicines with specific risks that required monitoring were appropriately monitored before their medicines were prescribed. Regular medicine reviews, including for high-risk drugs, were carried out for people who used the service to ensure their medicines were safe and appropriate for their needs.

Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. Prescribing data reviewed as part of our assessment confirmed this. For example, the number of antimicrobials issued by the provider was lower than local and national averages. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.

Staff received regular training, were competency assessed on medicines optimisation, and felt confident managing the storage, administration and recording of medicines. Staff managed prescription stationery appropriately and securely. Staff followed protocols to ensure they prescribed all medicines safely, and ensured people received all recommended medicines reviews and monitoring. Medicines were stored securely and at appropriate temperatures.

Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments.

From our review of clinical records, the provider had effective systems to manage and respond to safety alerts and medicine recalls. The practice maintained a drug safety alert list which was accessible to all staff.