All inspections: Iridium Medical Practice

Date of Assessment: 28 May 2026 to 18 June 2026. Iridium Medical Practice is a GP practice and delivers services to approximately 22,500 patients under a contract held with NHS England. The practice operates a branch site Poolway Medical Centre. We visited both sites during this inspection. The National General Practice Profiles states that 42% of the practice population are White, 41% Asian, 8% Black, 5% Mixed and 4% Other. Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the 1st decile (1 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 the practice was working within and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report. We carried out an announced, comprehensive inspection and assessed all quality statements under the 5 key questions safe, effective, caring, responsive and well-led.

The practice had a good learning culture, which placed patient safety, openness and transparency at its heart. Managers investigated incidents thoroughly. Patients were protected and kept safe because the practice thoroughly assessed and managed the risk of infection. Staff understood and managed risks. The facilities and equipment met the needs of patients, were clean, well-maintained and any risks were mitigated. There were enough staff with the right skills, qualifications and experience. Managers made sure staff received training and regular appraisals to maintain high-quality care. Staff managed medicines well and involved patients in planning any changes.

Patients were involved in assessments of their needs. Staff reviewed assessments taking account of patient’s communication, personal and health needs. Care was mostly based on latest evidence and good practice. Staff worked with all agencies involved in patients care for the best outcomes and smooth transitions when moving services. Staff made sure patients understood their care and treatment to enable them to give informed consent. Staff involved those important to patients and took decisions in patients’ best interests where they did not have capacity.

Feedback was mixed about whether patients were treated with kindness and compassion. Staff protected their privacy and dignity. They treated them as individuals and supported their preferences. Patients had choice in their care and treatment. The practice was exceptional at supporting staff wellbeing.

Patients were involved in decisions about their care. The practice provided information people could understand. Patients knew how to give feedback and were confident it was taken seriously and acted on. The service was mostly easy to access and staff worked to eliminate discrimination. Patients received fair and equal care and treatment. Staff worked to reduce health and care inequalities through social prescribing. Patients were involved in planning their care and understood options around choosing to withdraw or not receive care.

Leaders and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible, knowledgeable and supportive, helping staff develop in their roles. Staff felt supported to give feedback and were treated equally, free from bullying or harassment. 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 try new ideas.

We last inspected this provider in January 2025 when we found breaches of regulation in relation to good governance. We requested that the provider submit an action plan to address these breaches. Since the previous inspection the practice had made improvements and is no longer in breach of regulations relating to good governance.

Date of Assessment: 14 January 2025 to 11 February 2025. Iridium Medical Practice is a GP practice and delivers services to approximately 22,000 patients under a contract held with NHS England. The practice has a branch practice at Poolway Medical Centre. According to the latest available data, the ethnic make-up of the practice area is 41% Asian, 42% White, 8% Black, 5% mixed and 5% other. Information published by the Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the 1st decile (1 of 10). The lower the decile, the more deprived the practice population is relative to others.

We carried out an unannounced comprehensive assessment of all 5 key questions to assess the quality of services being delivered, following concerns we had received.

We found the facilities were clean and well-maintained and most risks were mitigated. However, staff did not always understand which incidents to report or demonstrate that learning was embedded. Medicines management processes required improvement.

Care was not always based on latest evidence and good practice and the provider could not evidence that decisions about care and treatment were always made with patients.

Staff protected patients’ privacy; however, patients and other healthcare professionals were not always treated with kindness and the service did not always support staff wellbeing.

The provider worked to reduce health and care inequalities. Generally, patients found it easy to access the service, however, patients did not always feel supported to complain.

Leaders and staff did not have a shared vision and culture based on listening, learning and trust. Leaders were visible, however not all staff felt they would be supported if they raised concerns.

We found breaches of regulation in relation to good governance. We have asked the provider for an action plan in response to the concerns found at this assessment.

We carried out an unannounced focused inspection at Iridium Medical Practice on 19 October 2022 in response to information of concern received. The practice was not rated at this inspection.

Following our previous inspection on 6 May 2022, the practice was rated good overall and for all key questions.

At this inspection, we found no changes to this rating.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Iridium Medical Practice on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection to follow up concerns reported to us.

The focus of inspection included:

management of the cold chain.

How we carried out the inspection

This included:

A short site visit.
Requesting and reviewing evidence from the provider.

Our findings

We based our judgement of the quality of care at this service on a combination of:

what we found when we inspected.

We found that:

Records seen showed that vaccines were being stored at appropriate temperatures to maintain their effectiveness.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services

We carried out an announced inspection at Iridium Medical Practice between 27 April 2022 and 6 May 2022. Overall, the practice is rated as Good.

The ratings for each key question are as follows:

Safe - Good

Effective - Good

Caring - Good

Responsive - Good

Well-led - Good

The practice has not been previously inspected under their current CQC registration.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Iridium Medical Practice on our website at www.cqc.org.uk

Why we carried out this inspection:

This inspection was a comprehensive review of a new provider.

How we carried out the inspection:

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

Conducting staff interviews using video conferencing
Completing clinical searches on the practice’s patient records system and discussing findings with the provider
Reviewing patient records to identify issues and clarify actions taken by the provider
Requesting evidence from the provider
A site visit

Our findings

We based our judgement of the quality of care at this service on a combination of:

what we found when we inspected
information from our ongoing monitoring of data about services and
information from the provider, patients, the public and other organisations.

We have rated this practice as Good overall

We found that:

The practice provided care in a way that kept patients safe and protected them from avoidable harm.
Safeguarding arrangements in particular were well established to help support and protect the practice’s most vulnerable patients.
We found appropriate recruitment checks were in place for staff working at the practice
We found effective systems for safely managing medicines and our review of clinical records found patients on high risk medicines were appropriately monitored.
The practice learned from incidents and complaints and implemented systems for minimising the risk of reoccurrence.
The practice premises were generally well maintained and infection prevention and control measures were implemented to minimise the risks to patients. However, some of the furnishings were not appropriate for a clinical environment.
Patients received effective care and treatment that met their needs.
Our review of clinical records found patients with long-term conditions received appropriate management and follow-up.
Staff received appropriate training and support in their roles.
The practice made effective use of social prescribing support available to ensure the health and wellbeing of their patients.
Staff dealt with patients with kindness and respect and involved them in decisions about their care. The practice was aware that there had been some concerns around reception and were taking action to improve and develop the reception team to improve the patient experience.
The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

We saw the following outstanding practice:

The practice was proactive in trying to address health inequalities and supporting their most vulnerable and complex patients. The practice actively referred patients and worked with two social prescribing teams which met different levels of patient needs. Data from the social prescribing teams showed the practice had referred nearly 400 patients to these services in the last year. The practice was able to provide numerous case studies of improved patient health and wellbeing as a result of these referrals and provided rooms for events such as stress management courses. There was a dedicated GP that worked closely with the social prescribers to provide holistic patient centred care. These patients had multiple social and health issues and made frequent contact with emergency and other services. The working relationship ensured good continuity and oversight of patient care and helped reduce the burden on other services. The practice was also a high referrer to IRIS (a service supporting patients at risk of domestic abuse).

Whilst we found no breaches of regulations, the provider should:

Replace chairs in clinical rooms that cannot effectively be cleaned.
Improve frequency of fire drills to ensure staff know what to do in the event of a fire.
Improve uptake of child immunisations and cancer screening programmes.
Continue to improve patient experience of the service.
Continue to take action to ensure the well being of all staff.
Hold regular meetings across all staff to ensure timely sharing of information.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Iridium Medical Practice

All Inspections

During an assessment under our new approach

During an assessment under our new approach

19 October 2022

During an inspection looking at part of the service

6 May 2022

During a routine inspection