We take our responsibility to provide safe, high-quality care extremely seriously. Since the CQC inspection, we have undertaken a comprehensive review of our systems and processes and have implemented a number of improvements. At the same time, the report highlighted areas of strength within the practice.
Strengths Highlighted in the Inspection
Safe:
- Proactive learning culture with open reporting of incidents and lessons shared.
- Effective systems and pathways for continuity of care and safe transitions.
- Safeguarding procedures understood, acted upon, and regularly reviewed.
Effective:
- Staff and services work well together to share information and ensure coordinated care.
- Support for healthier lives, including risk assessment and health promotion.
Consent procedures and person-centred care consistently applied.
Caring:
- Patients treated with kindness, empathy, and dignity.
- Individual needs considered, including cultural, social, and communication requirements.
- Independence, choice, and access to advocacy promoted.
Responsive:
- Person-centred care and flexible scheduling provided.
- Integration with external services ensures continuity.
- Accessible information and systems for feedback in place.
- Equity in access and outcomes actively supported.
Well-led:
- Shared vision, transparent and inclusive culture.
- Competent and approachable leadership.
- Freedom to speak up supported.
- Workforce equality, diversity, and inclusion promoted.
- Active partnerships and community engagement through PCN collaboration and events like the Winter Wellness Fayre.
We are building on these strengths while addressing areas requiring improvement to ensure all patients receive safe, effective, and high-quality care.
Here are some of the areas we have made changes:
Infection prevention and control
- Carried out an updated infection prevention and control audit aligned with current best practice standards.
- Clinical desks and chairs have been replaced.
- Sharps management procedures have been reinforced
- Clinical waste is being stored in appropriate bags.
- Spot checks are now undertaken to monitor compliance.
Environmental safety
- All window blinds have been secured.
- The BP monitor containing mercury that was in a store room awaiting disposal has now been disposed of.
- A risk assessment has been completed in relation to visibility of the waiting areas and posters have been introduced to encourage patients to inform staff if they are deteriorating or feel a patient in the waiting area is.
- Prior to the inspection all staff had completed mandatory fire safety training, including warden draining. Fire drills had taken place. Those staff who had not been present for the drills have been scheduled for catch up sessions.
Medicines safety
- We are actively reviewing all safety searches, with a structured programme now in place to ensure all reviews are completed and monitored.
- For patients who do not attend their annual monitoring appointments, prescribing intervals are being safely reduced to encourage engagement and compliance with essential monitoring. This approach ensures that all patients receive medicines safely and that clinical risks are minimised. All adjustments are clinically reviewed to ensure safe and effective care.
- A patient group directive filed in error was identified and removed.
Clinical supervision
- All non-medical prescribers, including ACPs and registrars, receive debriefs and supervision after each clinical session. Staff confirmed that supervision was effective and supportive. As not all supervision discussions were fully documented due to time constraints, we have now implemented improved recording on the clinical system, allowing us to generate reports to evidence that supervision and debriefs take place consistently.
- This ensures ongoing professional development, patient safety, and oversight of clinical practice.
Emergency equipment
- We have strengthened our checks of emergency equipment, with enhanced monitoring and clear accountability.
- The manual wheelchair has been replaced to ensure equipment is safe.
Cervical screening (cytology)
The practice continues to meet Quality and outcomes framework (QOF) requirements for screening coverage and sends out multiple invitations to eligible patients, including letters with FAQs to reassure..
An internal audit following the inspection showed that:
- Patients aged 50 and over are meeting targets
- Patients under 50 require additional engagement
- Messaging has been updated to clarify that screening is recommended even for those who have received the HPV vaccine, ensuring younger patients understand the importance of routine checks.
These actions form part of our ongoing commitment to continuous quality improvement and patient safety.
GP partnership – February 2026