Merchiston Surgery

Date of assessment: 2 March to 5 March 2026.

Merchiston Surgery is a GP practice and delivers services to approximately 13,500 people under a contract held with NHS England. The National General Practice Profiles state that the service has a higher-than-average number of registered people aged over 60. Information published by the Office for Health Improvement and Disparities shows that deprivation in the service’s population group is in the 8th decile (8 out of 10). The lower the decile, the more deprived the population is relative to others.

This assessment considered the demographics of the people using the service, the context the service was working within and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report.

This assessment covered 4 quality statements within the Safe and Well-led key questions to follow up on a previous breach of regulation from our assessment in July 2025. Since the last assessment, the service had made improvements and is no longer in breach of the legal regulation relating to good governance.

Following our last assessment, the service has implemented a series of actions to address concerns relating to clinical supervision, staff training, infection prevention and control processes, and overall governance arrangements. This included strengthening internal and external cleaning arrangements, introducing a new system to monitor staff training and compliance, scheduling regular staff supervisions, and establishing clearer speaking up arrangements.

Date of assessment: 15 to 18 July 2025.
Merchiston Surgery is a GP practice that delivers services to approximately 13,500 patients under a contract held with NHS England. The National General Practice Profiles state that the practice has a higher-than-average number of patients aged over 60. Information published by the Office for Health Improvement and Disparities shows that deprivation in the practice’s population group is in the 8th decile (8 out of 10). The lower the decile, the more deprived the practice population is relative to others.

This assessment considered the demographics of the people using the practice, the context in which the practice was operating, and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report.

This assessment covered the safe, effective, responsive, and well-led key questions.

The service demonstrated a positive learning culture, and people felt able to raise concerns. Managers investigated incidents thoroughly, and people were protected and kept safe. Staff understood and effectively managed risks. Facilities and equipment met people’s needs and were clean and well maintained.

People were involved in assessments of their needs. Staff reviewed these assessments, considering people's communication, personal, and health needs. Care was based on the latest evidence and good practice. Staff worked with all agencies involved in people’s care to ensure the best outcomes and smooth transitions between services. Staff made sure people understood their care and treatment, enabling them to give informed consent. Where people lacked capacity, staff involved those important to them and made decisions in their best interests.

People received fair and equal care and treatment. The service aimed to reduce health and care inequalities through training, patient feedback, and a plan for future premises adjustments. Some of which had already been implemented to improve accessibility. People were involved in planning their care and understood their options, including choosing to withdraw or not receive care.

Leaders and staff shared a vision and culture based on listening, learning, and trust. Leaders were visible, knowledgeable, and supportive, helping staff to develop in their roles. Staff were encouraged and had opportunities to provide feedback, and the practice demonstrated actions taken in response.

Staff understood their roles and responsibilities. Managers worked with the local community to deliver the best possible care and were receptive to new ideas. There was a culture of continuous improvement, with staff given time and resources to explore and implement new initiatives. We found there was a lack of regular documented clinical supervision for non-medical prescribers and healthcare professionals instigated by supervisors in line with provider’s policy.

We also found the provider did not retain cleaning schedules or records meaning they could not evidence when and how often the premises and equipment were being cleaned.
This resulted in a breach of regulations in relation to good governance. We have asked the provider for an action in plan in response to the concerns found at this assessment.