Iridium Medical Practice

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 patients were protected from abuse and avoidable harm.

At our last assessment, we rated this key question as requires improvement. At this assessment, the rating has changed to good.

The practice had responded to feedback from our last inspection, redesigning and embedding a strong learning culture which resulted in tangible improvements in care for patients. Systems were in place to facilitate safe and timely information sharing when patients moved between services. Staff worked collaboratively to identify, support and safeguard vulnerable groups. There were enough staff and they received the training and support they needed to provide high quality care. The practice assessed and managed risk to ensure the premises and equipment were safe for everyone. The practice was clean and staff took action to mitigate the risk of infection. Medicines were managed safely.
 

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.

At our last inspection we found that systems and processes to report and manage incidents and complaints were not effective. Staff and patients did not always feel supported to raise concerns and learning from significant events was not being communicated widely or effectively.

At this inspection we found that the practice had completely restructured their governance processes and placed safety, openness and learning at the centre. The practice had a strong, proactive and positive culture of safety, based on transparency and honesty. This meant staff had immediate access to information about incidents, including near misses on a digital system which allowed them to reflect and amend their own practice in real time prior to the outcome of a formal investigation. All staff told us they had regular team and practice meetings where learning from significant events was shared. The leadership team regularly reviewed the learning and significant event logs to identify any themes or trends and responsive action was planned. At our previous inspection there was evidence that not all significant events were being recorded, only 2 were recorded in the year 2025. In the first 6 months of 2026, a total of 9 had been recorded evidencing improved reporting structures and increased staff engagement with the process. A recent learning event had highlighted an opportunity to apply Jess’s Law. Jess’s Law was introduced in the NHS in September 2025 to encourage GPs teams to rethink a diagnosis if a patient presents three times with the same symptoms or concerns, particularly if symptoms unexpectedly persist, escalate, or remain unexplained. In response to these events staff were given training at the clinical meeting on Jess’s Law in order to emphasise the importance of the new rules.
 

At the previous inspection we found that there were ineffective processes for reviewing and actioning test results. Patients had complained there was a lack of continuity of care.

The leadership team had reflected on these findings and worked with patients and healthcare partners to design, establish and maintain systems of care, in which safety was always well managed and monitored. There were systems in place for processing information relating to new patients. The practice had a very mobile and transient population and received approximately 2,500 registration changes per year. They had outsourced registration to an external provider and this made the process quicker and easier for patients. The practice was registered as a safe surgery meaning anyone within the catchment area could register without the need to provide proof of address or identification. The practice worked with other providers to deliver shared care and when patients moved between services. For example, the practice had shared care arrangements with a substance misuse rehabilitation service and had recently become the locality hub for this service.

New processes were embedded which ensured test results were managed in a timely way with agreed key performance indicators (KPI’s) being monitored by the governance lead and fed into regular clinical governance meetings. Referrals were effectively managed and monitored with systems in place to identify rejected or delayed referrals and action them. Dedicated administrative staff provided safety netting for 2 week wait referrals ensuring that patients were offered appointments within the required time frame and attended those appointments. The practice utilised digital systems to facilitate information sharing. This enabled staff to access information from secondary care clinics as well as allowing out of hours care providers to access information from the practice.

Some patients still experienced a lack of continuity in the care. The practice tried to accommodate requests for specific doctors whenever possible and had undertaken work to improve continuity for high-risk groups of patients. For example, they had identified a cohort of house bound patients with complex needs who required repeated or regular home visits. These patients were often outside the scope of the advanced clinical practitioner who provided most of the regular home visits. In response to this the practice had implemented a dedicated GP home visiting service with 1-hour appointments to provide continuity and improve the quality of their care and treatment.
 

The practice worked with patients and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving patients’ lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The practice shared concerns quickly and appropriately.

At our previous inspection we found that safeguarding registers were not updated and not always accessible to the safeguarding team.

A named safeguarding lead and deputy were in place who had dedicated administrative support. All staff knew who the safeguarding leads were and how to raise a safeguarding concern. Systems were in place to share safeguarding information swiftly and appropriately. The safeguarding lead had dedicated clinics to assess patients referred to them and review the practice safeguarding registers. The registers were accessible to the relevant staff and all patients were appropriately coded and flagged on the clinical system.

All staff had training to a level appropriate for their role and safeguarding was discussed at all team and practice meetings. The practice held monthly safeguarding meetings involving health visitors and other members of the community multidisciplinary team (MDT).

Staff at the practice leading in safeguarding and health inequalities were also part of the Integrated Neighbourhood Team (INT) which included staff from the local NHS community trust. The INT was created to support vulnerable patients with complex health and social needs and they had a weekly MDT meeting to review patients who had been referred to them. All staff could refer patients to the INT. Staff were able to share examples of effective safeguarding including staff who spent several hours over multiple home visits supporting a vulnerable older adult to move into safe accommodation.
 

The practice worked with patients to understand and manage risks by thinking holistically. They provided care to meet patient’s needs that was safe, supportive and enabled patients to do the things that mattered to them. Emergency medicines and equipment were available at both sites. Systems were in place to ensure these were checked and monitored regularly and action taken when stock was out-of-date or had been used and needed replacement. Sealed individual anaphylaxis kits were available in every clinical room. Suitable risk assessments were in place for the emergency medicines which the practice had decided not to stock based on their patient population. All staff had completed basic life support and sepsis training.

At our previous inspection some patients told us they did not feel supported or involved in decisions about their care and did not always feel they had been signposted appropriately or received appropriate safety netting advice. During this inspection the clinical records we reviewed showed that appropriate care plans were in place and that patients were given safety netting advice on what to do if their condition deteriorated.

We found some emergency equipment was not stored in an appropriate way and did not have original packaging with expiry dates on it. The practice took immediate action to remove and replace it.

Feedback from this inspection was mixed. In the National GP Patient Survey Patient 89% of patients said they were involved as much as they wanted to be in decisions about their care which was slightly below the national average of 92% but an improvement on the practice’s result in 2025 of 82%.The practice had independently reviewed the results of the GP Patient Survey, shared them with staff and implemented an action plan to target areas for improvement, including strengthening shared decision making.

The practice detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. We inspected the main and branch site premises and found they were clean and well-maintained. Both sites were in multi-occupancy premises and shared with other organisations with maintenance carried out by the facilities management team. The leadership team had oversight of building maintenance records and all risk assessments. They had regular communication with the facilities management team to ensure that actions arising from risk assessments were completed in a timely way. For example, at the last fire risk assessment on 22 May 2026, high risk areas were identified and required immediate action. When we asked whether this work had been completed the practice advised us that it had taken some time to liaise with the building owner, gather quotes and arrange a suitable date for the work to be done but it was due to begin in a couple of weeks. A business continuity plan was in place and reviewed and updated regularly.

Processes were in place to ensure equipment was appropriately tested, serviced and calibrated. Minor inconsistencies identified during the inspection were promptly addressed by the provider and did not indicate any wider concerns regarding equipment maintenance arrangements.

Firefighting and evacuation equipment was in place and regularly serviced. Fire alarms and emergency lighting was regularly tested. Fire marshals had been appointed and trained. A recent fire drill had been successfully completed. Prior to this Iridium practice staff took part in fire drills arranged by the building manager, however, as the building was shared by a variety of services who may have many less mobile patients the Iridium leadership team felt the results did not adequately assess the efficiency of their teams’ response. They therefore arranged their own fire drill, recorded the results and shared the learning from this with the team.
 

The practice made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met patient’s individual needs.

As part of the governance review and restructure the practice updated its recruitment procedures and Human Resources (HR) record keeping systems. A lead was appointed for recruitment and staff records we reviewed showed clear, systematic record keeping, all relevant documents and checks had also been completed. The HR team had almost completed a retrospective audit and rectification of historical gaps in staff files and were simultaneously transferring paper records onto an electronic system. A new induction program had been implemented and the induction pack for locums had been reviewed and updated. Audits carried out by the leadership team showed that over the last 12 months staff turnover had reduced, the team had stabilised and sickness absence had reduced. The practice employed a large staff of approximately 70 people, with a mix of clinical and non-clinical staff. There were enough staff to provide safe services and to provide flexible cover for leave and sickness absence.

We found all staff were up to date with mandatory training and had had an appraisal in the last 12 months. A new digital system for recording and monitoring training had been set up which alerted managers and staff when training became due. There were clear requirements for mandatory training for each staff group including the level of training and frequency that was required. Although all staff told us the practice was very busy, staff we spoke with felt their workload was acceptable and staff felt able to approach managers if their workload was becoming unmanageable. Staff also told us the leadership team were understanding when personal issues impacted them and supported flexible working arrangements where appropriate.
The HR team had undertaken a review of current and historical records of staff immunisations which were now complete and up to date. Where staff declined vaccination individual risk assessments were in place.

All clinical staff we spoke with had regular supervision sessions which were documented. For all prescribers this included audits of prescribing behaviours and individual feedback on a monthly basis. This had been in place for several months and it was planned that in future prescribing audits would be done quarterly with the frequency increased if issues or concerns were identified for an individual.
 

The practice thoroughly assessed and managed the risk of infection. They always quickly detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. The practice had a comprehensive infection prevention and control (IPC) policy. All staff knew where to find the policy, who the IPC lead was and what their responsibilities were. The IPC lead had appropriate training and was proactive and motivated. An IPC audit was completed annually and we saw that actions from the latest audit had been completed. IPC training was included in new staff induction and all staff had completed training to an appropriate level. The IPC lead carried out regular handwashing audits and provided individual feedback.

The IPC lead kept a digital log of the single use equipment in each room including items such as the privacy curtains and this system alerted staff when items were about to expire using a colour coding system and email alerts. Advance planning took place so that for example, the last appointment of the day was blocked out for each clinic room so that the curtains could be replaced when due. Healthcare assistants supported the IPC lead in checking and monitoring all clinic rooms and were given protected time to do this.

There was an electronic system to record daily staff cleaning of clinic rooms via a QR code and this information was reviewed and monitored by the IPC lead. Spot checks were also carried out regarding room cleanliness. Cleaning contractors were employed by the building manager but there were open communication channels for practice staff if issues arose. The IPC lead also spent 1 day a week at the branch site and undertook the same checks there.

There were suitable arrangements in place to deal with sharps injuries and access to occupational health. Clinical waste was managed by the building manager and collected weekly.
Staff followed local guidelines from the Integrated care Board regarding antibiotic prescribing and had access to microbiology services at the local hospital. There were policies in place for the management of communicable diseases including allocating an isolation room.
 

The practice made sure that medicines and treatments were safe and met patients’ needs, capacities and preferences.

Clinical records we saw demonstrated care was provided in line with current guidance and medicines were managed safely. All patients who were prescribed high-risk medicines were monitored and reviewed in line with guidelines.

Staff involved patients in reviews of their medicines and helped them understand how to manage their medicines safely. Patients knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms. Staff received regular training and felt confident managing the storage, administration and recording of medicines. Staff managed prescription stationery appropriately and securely. Processes for the administration of medicines under patient specific directives which was not effective at our previous inspection had been reviewed and updated. A rigorous new system had been implemented which embedded GP oversight of the process. Digital systems ensured that the healthcare assistant giving the medicine could not proceed without authorisation of the PSD and provided an audit trail for monitoring.

Staff followed protocols to ensure they prescribed all medicines safely, and ensured patients received all recommended medicine 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, vaccines, and controlled drugs. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments. The provider had effective systems to manage and respond to safety alerts and medicine recalls. Staff followed established processes to ensure patients prescribed medicines with specific risks received recommended monitoring. 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. Systems were in place for patients to request repeat prescriptions and these were actioned by a duty doctor or pharmacist within 48 hours. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.

The pharmacy team managed all medicine related safety alerts and ensured that affected patients were traced and contacted. This information was cascaded verbally at clinical meetings and via email to all staff.