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 carried out an assessment of 8 quality statements under the Safe key question. 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 has changed to requires improvement. The service did not have a good learning culture and people were not always supported to raise concerns. Staff did not always involve patients to understand and manage risks. Staff were not always supported to deliver high-quality care. Recruitment and medicines management processes required improvement.

This service scored 47 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Systems and processes to report and manage incidents and complaints were not effective. Patients did not always feel supported to raise concerns and told us they were not always treated with compassion and understanding or they did not feel confident that changes would be made. Some patients reported they were left feeling intimidated or that they were not aware of how to complain. Staff told us that learning from incidents and complaints was discussed during practice or clinical meetings. However, at the time of the assessment, these meetings had not been taking place regularly for the previous 4 months. Not all staff we spoke with could recall examples of incidents or complaints and subsequent learning, even when learning directly involved them or their team. We found that staff did not always report all incidents/learning events. Not all staff where aware of which incidents they should be reporting nor could they all recall the difference between a significant event and learning event. The significant event and incident policy did not provide sufficient guidance on what the difference was between an incident and learning event. Feedback from staff about the learning culture was mixed. Not all staff we spoke with felt there was an open culture. Some staff reported good support structures in place if they raised concerns. Other staff told us they were not supported to raise concerns, action was not always taken or they were fearful of repercussions. We reviewed 4 complaints in detail. The provider could not demonstrate that all complaints were always investigated and responded to in line with their policy. The provider had carried out a complaints analysis for the complaints received between January and December 2024. We saw that learning and actions for key themes had been identified, however there was no comparison to the previous year, to monitor if trends in complaints had reduced and if previous actions had been effective.

The practice had systems in place to make referrals and monitor they had been accepted.

The practice had systems in place to summarise records for new patients.

However, feedback from staff included that test results were not always actioned appropriately or in a timely manner and that correspondence was not being managed in line with the provider’s policy. We found these concerns were corroborated by patient records and other information we reviewed during our assessment.

The practice’s policy for managing pathology and radiology requests did not give sufficient guidance to staff on how soon routine test results should be actioned. During our clinical searches we found evidence of non-urgent abnormal test results that had not been actioned for 3 days. When we raised this with the provider, we found it was normal practice for the GP concerned to delay actioning results until their allocated non-clinical day of the week. The GP told us they had reviewed the results but there was no record of them doing so on the clinical system. There was no clear oversight of the management of test results by the leadership team.

The provider told us that a new role had been created to improve oversight of workflow processes including management of results and letters but this staff member was not yet in post.

Patients complained of lack of continuity in care and not being able to see their preferred GP. Three GP partners had left the practice 3 months before our assessment. The provider told us of the action they had taken to provide more continuity for patients in the long term.

Before the assessment, CQC received information that staff did not have the required IT access to order stock/supplies, on one occasion the practice had run out and they had borrowed supplies from another organisation. We were able to corroborate this information but found neither of these issues had been reported as an incident and investigated to understand the cause.

Safeguarding policies were in place and known to staff. From staff files we reviewed, we found 3 out of 4 staff had completed relevant training.

There had been a recent change in the safeguarding lead. The new lead had implemented processes to manage any new information of concern that came into the practice, however there was not effective oversight over existing concerns or registers.

The practice maintained a list of vulnerable patients (safeguarding registers). However, during the assessment, the lead for safeguarding was not able to find the registers on the clinical system and the practice could not demonstrate when the registers had last been reviewed and updated.

The provider told us, following the assessment, they had taken immediate action to review registers and had implemented processes to ensure they were kept up to date.

From records that we viewed, we saw that they had been coded correctly and household members were also coded correctly where appropriate.

The practice held weekly multidisciplinary clinics with other healthcare professionals to discuss their very vulnerable and complicated adult patients.

We saw evidence of meetings with health visitors to discuss vulnerable children on the safeguarding register.

Before the assessment, we had contacted the provider, about safeguarding concerns we had received. The provider responded and told us they had investigated our concerns. During the assessment, staff continued to raise concerns about their safety particularly within one area of the premises. We asked the provider about who accessed this area of the premises and how it was used but did not receive satisfactory assurances that correlated with our observations and staff feedback when we visited.

We also found the provider had not reported our concerns as a significant event in line with their policy. Following the assessment, the provider told us they had carried out a risk assessment and did not feel it was a learning event.

Our review of do not attempt cardiopulmonary resuscitation (DNACPR) forms indicated that forms were reviewed by the practice and patients and/or their carers were appropriately involved in decision making.

However, the service did not always work well with patients to understand and manage risks.

During our inspection of the main practice, we found that some emergency equipment items were missing and one emergency medicine was also not on site. The provider had not carried out a risk assessment to decide which emergency medicines they would keep on site and how they would manage risk in the absence of storing all suggested emergency medicines.

The provider took immediate action to improve and when we inspected the branch practice, we found that all recommended items of emergency equipment and medicines were available.

Staff could recognise a deteriorating patient and knew of action to take. Staff told us that patients were advised on risks related to their condition and actions to take if their condition deteriorated. However, the practice could not evidence that action or care plans were always completed with the patient and that patients were fully advised on safety netting advice.

From patient feedback we received we found that patients did not always 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.

The national patient survey showed of those patients who completed the survey, 85% felt they were involved as much as they wanted to be in decisions about their care and treatment. This was lower than the local result 89% and National result 91%.

Results from the practice’s in house survey December 2024, showed that 92% of patient’s who responded to the question felt they were involved as much as they wanted to be in decisions about their care and treatment during their last general practice appointment.

Processes were mostly in place to ensure the premises and equipment were maintained. Health and safety risk assessments were undertaken and risks identified had been addressed. There was a business continuity plan in place which was monitored and reviewed. During our inspection of the main practice and the branch practice we found both sites were well maintained. However, our observation of the waiting area at the main practice raised some safety concerns which we raised with staff at the time. Both sites were shared with other organisations and maintenance was carried out by the building management team. We found the provider had oversight of risk assessments related to the buildings and there were processes in place to communicate with building managers. During the inspection of the main site, staff were not able to produce evidence of safety risk assessments. Evidence was sent following the site visits and was satisfactory. We found there were processes in place to ensure that equipment was safe and calibrated at the main practice however during the visit to the branch practice we identified that the vaccine fridge and defibrillator had not been re-tested as safe for use. Last tested May 2023. The provider told us equipment had been re-tested when testing was due, however, they did not provide evidence of this. We were sent evidence following the site visit that showed this equipment had been tested in February 2025, after our site visit. We also found staff could not demonstrate how they accessed the Control of Substances Hazardous to Health (COSHH) risk assessment at the main practice. The fire drill carried out in August 2024 at the building which Iridium Medical Practice shares with other organisationswas unsatisfactory. The provider told us a repeat fire drill had not been carried out. However, they had been working with the building owner to improve processes. The fire evacuation plan for the main site had not been reviewed and updated following the departure of staff who had fire safety roles.

The provider could not demonstrate that training was up to date for all staff or that clinical supervision and appraisals of all staff was managed appropriately. Safe recruitment practices were not always followed. Staff told us the high turnover of both clinical and non-clinical staff was impacting on their workloads. We saw that some non-clinical staff worked additional hours on bank holidays and weekends to reduce administrative backlogs. Some staff reported concerns that their workload was not manageable and staff were being asked to carry out duties that did not align with the provider’s policies.. The provider told us they had successfully recruited 2 new clinical and non-clinical staff. At the time of the assessment these new staff had not yet started. We reviewed a sample of staff files and found that all files did not contain relevant information. Induction paperwork we were sent after the assessment, did not demonstrate that staff had received an effective induction. We were sent evidence of staff contracts following the assessment, however 2 out of 3 of these had not been signed by the staff member. The provider could not demonstrate that they had effective processes to ensure staff had the required immunisation when they began employment and on an ongoing basis. . When we asked how the leadership team maintained oversight of staff training, we received different and conflicting responses at different times in the assessment. The provider could not demonstrate that all staff were up to date with required training or role specific training.. Clinical staff told us formal clinical supervision had been on hold since September 2024 and they were unclear of the plans going forward. Staff also told us they were not aware of any formal monitoring of their prescribing decisions. There were no details within the provider’s training guide on which level of training should be completed or how often training should be completed.

There was confusion amongst staff about who the lead for Infection prevention and control (IPC) was.

There was also confusion about cleaning arrangements. Not all staff were aware a new system had been implemented to record information electronically.

From staff files we viewed, 2 out of 4 staff were not up to date with required training.

During the site visit of the main practice, staff were not able to locate the IPC policy, waste consignment sheets or the 2024 IPC audit. Staff told us clinical waste was managed by the landlord and we were sent evidence of clinical waste consignment sheets, following the site visits.

The provider carried out spot checks of clinical rooms to monitor IPC standards.

Clinical staff complained of high workloads and felt additional responsibilities had been placed on them in the absence of anIPC lead.

The provider did not have effective processes in place to collect and monitor information relating to staff immunisation status.

We saw that the latest IPC audit was carried out on 3 January 2025 and showed 98% compliance overall. Staff who carried out the audit had marked on the audit that risk assessments would be completed for staff who did not have Hepatitis B immunisations where required.. However, from staff files we reviewed, either information about immunisation status or a completed risk assessment was missing.

We were told that any actions resulting from the IPC audit would be discussed with the building management team and cleaner.. However, the action plan did not include all identified actions.

Patients told us they could get appointments for Flu/COVID vaccinations. Feedback from care home staff was mixed. One care home reported that residents had received Flu and COVID vaccinations as expected, however, another care home told us Flu vaccinations were delivered later than usual and some residents did not receive COVID vaccinations at all. This was reported by the care home to the Integrated care board (ICB) at the time.

Some medicines management processes required improvement.

The process for patient specific directions (PSD) was not effective.

Patients did not always feel involved or fully informed about risks and benefits of treatment.

Some patients found it easy to order repeat prescriptions, other patients complained of delays or repeated issues with prescriptions. There was confusion amongst staff about the process, resulting in delays. The provider had recently changed their policy and the processing time had reduced from 72 to 48 hours. This had not been effectively communicated to staff.

Care home staff reported there were often delays in receiving medicines.

Our record reviews indicated that medicine reviews did not always contain relevant information. The provider told us they were working on a template to improve record keeping.

Staff mostly followed protocols to ensure they prescribed medicines safely and patients received recommended monitoring.

However, during our record reviews we found that patients prescribed a medicine to treat high blood pressure were not always monitored in line with guidelines. The provider sent us information, following the assessment, showing they had acted to review and improve their systems for this patient group.

The provider had systems to manage and respond to safety alerts. However, , the provider could not demonstrate that staff had informed patients about specific risks related to a medicine used to help manage type 2 diabetes. The provider told us that they had contacted all relevant patients following the assessment to make patients aware of these risks.

The provider did not have effective processes to ensure the security of blank prescription stationery.

Prescribing data for antibiotics that we reviewed as part of our assessment indicated that practice prescribing was in line with local averages. However, staff told us they did not receive individualised data about their prescribing behaviour, that would promote improvements.