Merchiston 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.

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.

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

The service made sure there were enough qualified, skilled and experienced staff, who now received effective support, supervision and development. 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. Staff training was up to date, the learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence. Safe recruitment practices were followed.

Since our last assessment, leaders had reviewed the training policy and confirmed that no changes were required. However, they continued to explore ways to ensure staff fully understood the policy and to make training more engaging and meaningful. They also ensured staff members were only assigned training that was relevant to their role and responsibilities. Staff were encouraged to take protected time to complete their mandatory training, and the system now sends automated reminders to both the staff member and their line manager ahead of the due date. This strengthened oversight of staff training, which managers were now monitoring.

The service also worked to reduce duplication of training for staff who were employed across multiple primary or secondary care settings. They did this by checking and verifying the staff member’s existing training compliance and adding this information to their own monitoring system.

The service had a duty doctor on site every day. The duty doctor was available to support people using the service and provided advice and escalation support to a range of staff. The duty doctor also worked with trainees, allowing them to be allocated cases and work alongside the duty doctor for supervision, feedback, and hands‑on experience.

Where some areas of training were identified as non‑compliant, the service was able to demonstrate this was due to staff sickness or the onboarding of new recruits. The service confirmed these staff members were booked onto the next available session, where face‑to‑face learning was required. The service had also implemented effective mitigation for these staff members, such as no lone working until training had been completed as required by the service.

The service had introduced supervision policies for relevant roles and used templates within the clinical system to record supervision notes for newly qualified GPs, as well as mentor meeting notes. These notes included positive discussions, identified learning, actions required, areas needing support, and space for questions and reflections.

However, templates for clinical supervision for other clinical staff were not yet fully embedded. Although the templates had been introduced and there was evidence of initial auditing of clinical notes and prescribing, follow‑up reflective discussions had not yet begun in line with their own policy. In response, leaders told us this would be implemented.

Whilst the service did not yet have a centralised process to monitor compliance with clinical supervisions, and responsibility to complete these currently sat with individual line managers, leaders confirmed they were exploring how to address this.

The service now assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Since our last assessment, new processes for cleaning and monitoring the service had been introduced. Evidence provided at this assessment showed these were clearly documented and shared within policies agreed between the service and its external cleaning provider. Evidence of cleaning records and cleaning audits were also available at the time of inspection. The cleaning records now contained clearly defined frequencies for required tasks across the whole service. The external cleaning provider completed monthly audits and shared their findings with the service. The service had worked with the cleaning provider to ensure all data sheets relating to Control of Substances Hazardous to Health (COSHH) products were now appropriate for the service, and all associated risk assessments were available.

The service had an infection prevention and control (IPC) lead and was in the process of training 2 additional staff members to strengthen oversight and support the shared responsibility of the role. IPC had been made a standing agenda item at nurse meetings, ensuring ongoing oversight and regular discussion of key topics. The IPC lead continued to carry out frequent checks of hand hygiene and aseptic non‑touch technique audits to demonstrate staff were following appropriate protocols as required.

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