Creech Medical Centre

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 people were protected from abuse and avoidable harm.

This is the first inspection for this service since its registration with CQC. We assessed all the quality statements in the safe key question. This key question has been rated as good.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff felt supported to raise concerns and told us they were treated with compassion and understanding. Leaders encouraged staff to raise concerns when things went wrong. Staff felt there was an open culture, and that safety was a top priority. The service closed for half a day every 3 months to hold a whole staff team meeting where learning from clinical issues and complaints was discussed. Learning from incidents and complaints resulted in changes that improved care for others. For example, changing the support provided for trainee GPs hosted by the service.

The service had recently implemented a weekly learning session for clinicians to give them an opportunity to get together to learn, share and discuss changes in systems, processes and guidance.

Representatives from the Patient Participation Group (PPG) felt the service took concerns seriously and proactively made improvements to the service.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care. However, a backlog of people’s records waiting to be summarised when people moved between different services, was identified.

There were systems in place for processing information relating to new people joining the service. However, there were 739 records waiting to be summarised, this was approximately 14% of the people registered at the service. The oldest record waiting to be summarised was from June 2022. The service was aware of the backlog and had an action plan to clear it by March 2027. These records had been reviewed when they arrived and given a colour relating to how urgent they were to be summarised and processed. Any record rated as high-risk were prioritised. During the inspection, we asked for action plan to be reviewed for clarity on how this backlog was going to be cleared. Following the inspection, we were provided with an updated action plan with extra detail on how they are going to work through this backlog.

The service worked with other providers to deliver shared care and when people moved between services. Referrals and test results were managed in a timely way.

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

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. Safeguarding was a standing item on the agenda at regular meetings. The service regularly reviewed a list of vulnerable people and acted on concerns working in partnership with other organisations.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Systems and processes assessed, monitored and managed risks to people’s safety. People were informed of any risk relating to their care and staff documented this in people’s records.

As part of our inspection, a number of set clinical record searches were undertaken remotely by a CQC GP specialist advisor. These searches were visible to the service. Our clinical searches identified 31 people prescribed mirabegron (a medicine to treat an overactive bladder) of which, 3 had not had appropriate monitoring. We reviewed these records and found 1 person had an appointment booked and the other 2 had been contacted to invite them in for monitoring.

Emergency equipment was available and maintained. Staff could recognise deteriorating symptoms and knew of action to take. People were advised on risks related to their condition and actions to take if their condition deteriorated.

The service had policies and processes in place to detect and control potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Contracts were in place to ensure the premises were appropriately maintained. Health and safety risk assessments and audits were completed, and any identified risks had been effectively addressed.

There was a business continuity plan in place which was monitored and reviewed.

Step-free access and ground levels rooms support people with accessibility needs.

The service 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 people’s individual needs.

There were a range of clinical and non-clinical roles within the service. We found training was up-to-date, learning needs and development of staff were managed appropriately. Staff had received an annual appraisal.

Safe recruitment systems and processes were followed and where information was missing from staff files, risk assessments had been completed.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service had a designated infection, prevention and control lead and all staff had completed relevant training. Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks. Sharps bins and clinical waste were managed appropriately.

There was a process to record staff vaccinations in line with national guidance. Where evidence was missing, a risk assessment had been completed.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

Staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely. People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms.

Staff received regular training, were competency assessed on medicines optimisation, and felt confident managing the storage, administration and recording of medicines. Staff managed prescription stationery appropriately and securely.

Medicines were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines and vaccines.

Waste medicines were recorded and disposed of appropriately. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments. However, during the onsite visit, we found 2 oxygen cylinders laying down, stored incorrectly. The service took immediate action to address our concerns and repositioned the cylinders, so they were stored correctly.

The service had effective systems to manage and respond to safety alerts and medicine recalls. Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring.

Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment. The service regularly reviewed and monitored their antimicrobial prescribing. Verified data reviewed as part of our assessment confirmed this. For example, for the period from June 2025 to July 2026, the number of Co-amoxiclavs, Cephalosporins or Quinolones antimicrobials issued by the service was observed to be 3.5% which was lower than the expected 8.3%.

We reviewed a sample of Patient Group Directions (PGDs) (a written instruction for the supply and/or administration of a named licensed medicine for a defined clinical condition by named registered health care professionals without them having to see a prescriber) and found they had been completed correctly in line with guidance.