Tieve Tara Medical Centre

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• 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.

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

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We found that the service had a proactive and positive culture of safety, based on openness, and ongoing learning. To support this approach the provider had developed and implemented policies and processes for complaints, compliments, significant events, and quality improvement work. These documents were available to staff on the provider’s shared information access platform and in hard copy.

From staff questionnaire feedback and interviews we heard that staff knew how to report and record incidents. The provider told us that their intention from their incident reporting approach was not to proportion blame, but to encourage reporting, and to share learning to improve the service and prevent recurrence. Learning from events and incidents were shared at a wide range of meetings such as daily huddles (mini daily staff meetings), at general and clinical team meetings, and at formal risk and governance meetings. It was noted that that some meetings had recently been suspended for a short period of time, due to changes in the staffing model at the practice and the need to induct new staff into the practice. We saw that these meetings had been reestablished by the time of our assessment. We saw incidents had been investigated and appropriate actions taken. For example, the provider had taken action to reduce a backlog of correspondence of letters for coding and processing. We also saw that, when necessary, patients had been informed of incidents which impacted them in line with Duty of Candour requirements.

The provider undertook a number of clinical searches and audits to support their service improvement work and learning, and as part of their clinical supervision oversight. Audits were appropriate and included clinical and non-clinical subject areas. Whilst some audits were well completed, others were seen to lack depth.

Over the previous 12 months the provider had recorded 28 incidents and events, and received 13 concerns and complaints. Similar to incident reporting, the learning from complaints was used to drive quality improvement across the organisation. We also saw that in 2025 that compliments regarding the service had risen to 18 from 2 in 2023 and 0 in 2024.

The service worked with healthcare partners to establish and maintain safe systems of care. They made sure there was continuity of care, including when people moved between different services.

There were systems in place for processing information relating to new patients joining the practice. At our last assessment of the service in 2024 we saw that there had been a backlog in the summarising of new patient records. In response to this the provider had taken actions which included additional staffing. At this assessment we saw that this backlog had been effectively tackled, and that only 6 records were in the process of being summarised.

We saw that referrals and test results were managed in a timely way, and that high priority referrals including cancer 2-week waits were subject to regular monitoring and oversight. Incoming correspondence and actions were being managed by the provider, and we saw evidence which showed that outstanding correspondence rates had fallen, and were assessed in a timely manner. Similarly, staff tasks were monitored and actioned accordingly. The service had a Caldicott Guardian in place to ensure that information was shared safely and appropriately.

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

During interviews with staff we discussed safeguarding and found they had a good overall understanding of the subject, and gave examples of when they would raise concerns with their safeguarding lead. Safeguarding was supported by detailed policies and processes, all of which had recently been reviewed. In addition, the practice had the specific support of their own provider’s in-house safeguarding team. Checks on training records showed that staff had been trained in safeguarding to levels appropriate to their roles.

Safeguarding was discussed at regular multi-disciplinary team meetings, when cases of concern could be discussed with others, and at scheduled internal meetings and daily mini-meetings (huddles).

The practice maintained a list of vulnerable patients and acted on concerns, working in partnership with other organisations. We saw that the practice utilised their clinical system to support their safeguarding approach. For example, they recorded if a child was not brought in for an appointment, or had attended accident and emergency services, and used this to track any developing concerns.

The service worked with people to understand and manage risks. Staff provided care to meet people’s needs that was safe, and supportive.

Results from the 2025 National GP Patient Survey showed that 94% of patients reported that they were involved as much as they wanted to be in decisions about their care and treatment during their last appointment, compared to a local and national average of 91%. However, only 78%of respondents said that the last healthcare professional they saw or spoke to was good at listening to them, compared to local and national averages of 87%.

Staff we spoke with knew how to react to emergency situations such as calling for support, and were aware of the location of emergency medicines and equipment. These medicines and equipment were checked by the practice on a regular basis to ensure that they were suitable for use.

At the last assessment of the service in 2024 we identified that some non-clinical staff were unaware of “red flag” symptoms for potentially deteriorating patients, and that there was no evidence of formal sepsis awareness training for staff. At this latest assessment we found that staff had a good awareness of the signs of a patient with deteriorating health, and knew of actions to take to keep them safe, and to effectively respond to the situation. We also saw training records which showed that staff had received sepsis awareness training, in addition to other necessary emergency training such as basic life support.

The service worked to identify and control potential risks within the care environment. They ensured that the equipment, facilities and technology available supported the delivery of safe care.

The provider had put processes in place which gave assurance that health, safety and wellbeing requirements were met. For example, necessary health and safety risk assessments had been undertaken such as a legionella risk assessment. At the previous assessment it was found that there was a lack of oversight of health and safety processes, and that action had not been taken in a timely manner to put in place safety measures and remedial actions. At this assessment we saw that these required actions had taken place including the regular monitoring of water temperatures.

Overall, we saw that the premises was in a good structural condition and that safety equipment had been maintained in line with requirements. Fire risks were managed, and we saw evidence that regular fire alarm checks and fire evacuation drills had been carried out.

There was a business continuity plan in place which was monitored and reviewed, and which could be implemented when required.

During our site visit to the practice, we saw that policies and processes in respect of recruitment, induction and ongoing appraisal were in place and being adhered to. Necessary recruitment checks had been undertaken, and staff had received Disclosure and Barring Service (DBS) checks appropriate to their role. Whilst some staff told us that they felt well supported during their induction period, others informed us though that whilst induction had been undertaken with them in some form, that they felt that it could be improved upon. From a sample of records reviewed we saw that appraisals had been undertaken, and that checks were made on professional registration for clinical staff as required.

At the previous assessment we had identified that whilst clinical staff received regular sessions of supervision, this did not include the undertaking of prescribing audits for non-medical prescribers. At this assessment we saw examples of consultation and prescribing audits that had been undertaken for such staff. We also saw that during staff supervision and appraisal sessions that training requirements and requests were discussed. Staff told us that in the majority of cases training requests were sanctioned by the provider.

At the time of our assessment the provider was in the process of delivering a significant transformation project at the practice. This was aimed to both ensure sustainability, and to make sure quality and care processes were maintained and were fit to meet the needs of their population. Workstreams which were part of the transformation project included workforce development and staffing, and demand and capacity management. Activities had included a move in the model of GP provision away from the use of regular locum GPs to one of recruiting substantive GPs. We saw that this process was ongoing, and was being managed via the interim use of short-term contracted GPs combined with a phased introduction of new GPs. Simultaneously, the provider had undertaken capacity modelling. Whilst this change in staffing away from locum usage should prove to be positive in the long-term, the provider recognised that this move has impacted negatively on continuity of care. Some staff feedback to us indicated that they felt that more capacity was required for appointments.

We saw that over this transformation period and for service sustainability the practice had initially moved from 38 GP sessions to 24 GP sessions being available per week. To mitigate against this reduction in GP sessions, the service had other clinical sessions provided by an advanced nurse practitioner, a clinical pharmacist, and support from their primary care network pharmacy team. The provider reported to us that that they had been successful in recruiting 4 substantive GPs to the practice and that these new staff would be joining the team in the near future, and that they also were looking to recruit an additional GP. The provider was aware of the need to effectively embed these changes into the practice.

During our onsite visits we examined staff rotas and saw that necessary staff cover, and skills mixes were in place.

The provider had put effective measures in place to manage infection prevention and control (IPC). This included the appointment of a senior trained staff member to act as the practice’s IPC lead, the development of an IPC policy, and undertaking regular IPC audits and checks. When audits had identified IPC concerns, we saw that the provider had taken appropriate action. For example, we were informed of past issues regarding standards of cleaning. We heard that the provider had raised this with their cleaning company. During the onsite visit we found clinical rooms, offices and waiting areas to be in a clean condition. However, we saw that the cleaner’s storage areas had not been maintained to suitable standards of cleanliness. In addition, exterior areas to the rear of the building required the clearance of extraneous items such as a discarded chair, and bags of leaves and windblown litter. We raised this with the provider who later contacted us to confirm that cleaning and clearance works had been authorised, and that the redecoration of areas had been planned.

Staff undertook IPC training during their induction, and annually thereafter. We saw that as part of the recruitment process the provider had assurance that staff had received the necessary immunisations and vaccinations to undertake their roles safely. Staff who handled clinical specimens knew how to undertake this safely and in line with guidance. Checks made during the onsite visit showed that adequate supplies of personal protective equipment were available. Hazards such as sharps risks were managed appropriately, and the provider had a clinical waste disposal contract in place.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. The provider had processes in place for the management and oversight of prescribing, including audits. We saw evidence that staff involved people in reviews of their medicines and conditions. Staff received regular training, were assessed on their medicines prescribing, and prescription stationery was appropriately managed. Staff followed protocols to ensure they prescribed all medicines safely, and generally ensured people received the required timely medicines reviews and monitoring.

Medicines and vaccines kept in the practice were stored securely and at appropriate temperatures, we also saw that staff regularly checked the stock levels and expiry dates for all medicines held.

At previous assessments we had some concerns regarding the effective monitoring of patients in receipt of certain medicines, and the actioning of medicines safety alerts. At this assessment we saw that overall, the management of medicines had improved, but that there were still areas of medicines management that required improvement. For example, during our previous assessment in 2024 we saw that 30 out of 122 patients prescribed direct oral anticoagulants (DOACs - used to treat and prevent blood clots, atrial fibrillation, and stroke) had not received the required monitoring. In addition, of these patients 108 had not received a specific kidney function check (Creatinine Clearance) in the previous year. At this assessment we found that of 134 patients now in receipt of these medicines the number of patients who had not received the required monitoring had fallen to 10, and only 2 patients had not had a Creatinine Clearance check undertaken. When we looked at 5 records in detail, we still found that most of these patients still had not had the monitoring done within the expected timeframes. We also saw evidence that some repeat medication had been authorised for patients beyond their monitoring period. When we discussed these points with the practice, they confirmed that all patients we had identified had been reviewed, with actions been taken to address these concerns, and safeguards put in place to prevent repeat prescribing outside review dates. In addition, they also confirmed that new recall processes were due to be put in place for required patient monitoring.

The previous assessment had also identified concerns with the actioning of safety alerts. At this assessment we saw that the practice had procedures in place to receive, disseminate and discuss safety alerts, and that staff understood this process. During our remote clinical searches we saw that of 5 patients prescribed Topiramate (a medicine used to treat epilepsy and migraine but which is contraindicated in pregnancy to women with child bearing potential, due to risks associated with use to the unborn child) that 4 had been managed effectively, however, 1 record still showed no discussion of risks with the patient, and that no comprehensive pregnancy prevention programme was in place. When we raised this with the practice, they confirmed to us that they had subsequently contacted the patient, and that contraceptive advice had been given.

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.