Sinnott 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

There had been efforts to promote a proactive and positive safety culture, supported by openness and honesty. Safety concerns had been heard, and incidents had been investigated and reported. Lessons learned were used to inform practice. Emergency management processes had been established, and safety netting measures were included in the triage system to help reduce clinical risks. Infection prevention and control had been monitored, with actions taken when necessary to safeguard individuals. The premises and equipment had been safely maintained. However, we identified areas where systems and processes had not always been reliable or appropriate to keep people safe.

This had been the first assessment for this service since its registration with the CQC. This key question had been rated as requires improvement.The service was in breach of legal regulations relating to staff training and recruitment, as well as medicines optimisation, where we identified concerns regarding patient monitoring and adherence to clinical guidance.

The provider acknowledged these findings and stated that key processes have been reviewed and reinforced since the appointment of a new Practice Manager in September 2024.

This service scored 56 (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 fostered a proactive and positive safety culture, grounded in openness and honesty. Staff listened actively to safety concerns, and incidents were investigated and reported appropriately. Lessons were learned and used to continuously identify and embed good practice.People felt supported in raising concerns and described staff as compassionate and understanding. Managers promoted openness, and staff felt confident speaking up when things went wrong. Clinical issues were discussed during team meetings, encouraging shared learning and continuous improvement.Safety was supported by clear processes for reporting incidents. Complaints were systematically recorded and investigated, and when things went wrong, staff offered apologies and support. Learning from incidents and complaints led to meaningful changes that improved the experience of others. We noted that not all complainants were provided with the contact details for the Parliamentary and Health Service Ombudsman (PHSO) in case they were dissatisfied with the service’s response. Following our feedback to the provider, we were informed that all future complaint responses will be issued using their newly developed complaints template letter.

The national GP patient survey conducted between December 2024 and April 2025 received 125 responses. Of these, 79% of patients reported being involved as much as they wanted to be in decisions about their care and treatment, and 84% felt their needs were met during their last appointment. The former result was tending negative for the service.

Leaders and staff reported that a designated team was responsible for managing referrals through the NHS e-Referral Service. Staff monitored the system to ensure referrals to specialist services were accurately documented, included the correct information, and were processed without delay. Safety netting procedures were in place to ensure all patients were appropriately followed up. Routine referrals were monitored to confirm whether patients still required specialist input or if their condition had deteriorated.

Leaders also explained that they maintained oversight of workflow tasks to ensure timely responses. A system was in place to summarise patient records effectively.

Monthly multidisciplinary team meetings were held to review and improve outcomes for people with complex needs.

A safeguarding GP lead and a deputy lead were in place. Internally, clinical staff met monthly during a clinical meeting where safeguarding was a standing item on the meeting agenda. Non-clinical staff were aware of the appropriate channels for reporting safeguarding concerns.

The service also monitored children who were not brought to appointments. Non-clinical staff told us they were aware of who to report any safeguarding concern to.A review of patient records confirmed that the service had a system in place to flag vulnerable adults and children to staff. Safeguarding policies were in place and well understood by staff. A review of staff’s recruitment files showed that not all staff were appropriately trained in safeguarding and the Mental Capacity Act specifically required for clinicians. Following the assessment the provider evidenced that staff had completed the relevant safeguarding training; however, Mental Capacity Act training for two clinicians was not completed until after the assessment.

Staff worked with individuals to understand and manage risks holistically. They delivered care that was safe, supportive, and tailored to meet people’s needs, enabling them to engage in activities that mattered to them.

Emergency equipment was available and properly maintained. Staff were able to recognise when a patient’s condition was deteriorating and understood the appropriate actions to take. Patients were advised about risks related to their condition and were given guidance on what to do if their condition worsened.

Staff were aware of the services business continuity plan which was regularly reviewed and monitored to ensure the service remained prepared for potential disruptions.

During our on-site assessment, we observed that the premise was clean, well maintained, and conducive to safe care. The service had effective systems in place to monitor and comply with mandatory risk assessments, including fire safety and legionella testing, which helped ensure the safety of both patients and staff. Records confirmed that medical equipment was regularly maintained, calibrated, and tested.

The service had a comprehensive business continuity plan that addressed various risks, including fire, flooding, loss of computer or telephone systems, and staff shortages.

The provider's systems to ensure and demonstrate safe staffing through effective recruitment, training, and safeguarding compliance were not reliably operated. This lack of robust governance meant the service could not assure itself or others that staff were always suitably vetted, trained, and competent.

A review of staff files revealed significant gaps in evidence. For one staff member, there was no proof of ID, appraisal, or nine mandatory training certificates available at inspection. While the provider later supplied evidence that most training was completed, two certificates (infection prevention and information governance) were only finalised after the assessment. Furthermore, the provider's system for maintaining ongoing Disclosure and Barring Service (DBS) checks was not followed; for a locum GP, reliance was placed on an online update service without evidence of the three-yearly checks required by practice policy.

These issues reflected a systemic failure in administrative oversight and record-keeping. The provider failed to maintain accurate, accessible, and up-to-date records to demonstrate staff suitability at the point of inspection. Following the assessment, the provider submitted extensive evidence to address the gaps identified.

Patient feedback from the national GP Patient Survey, carried out from December 2024 to April 2025, showed that 81% of patients had confidence and trust in the healthcare professional they saw or spoke to, which was below the local average of 90% and the national average of 93%.

People we spoke with told us they found the premises clean and tidy and had no concerns relating to infection prevention and control (IPC).The service had a designated IPC lead, and all staff had received relevant training. Cleaning schedules were in place and followed consistently. Risk assessments and audits were completed, with actions taken to mitigate identified risks.We reviewed the recruitment files of four staff members and found that two had not completed IPC training at the time of assessment. The provider explained this lapse was due to a configuration error in their training platform, which has since been rectified.Following the assessment, evidence was provided confirming that both staff members subsequently completed the required training.

As part of the assessment, a series of clinical record searches were conducted by a CQC GP Specialist Advisor (GP SPA), with the provider’s consent. These searches aimed to evaluate whether the service was delivering care and treatment in accordance with current legislation, standards, and evidence-based guidance.The practice demonstrated partial compliance with evidence-based care and treatment standards, with several areas identified for improvement to ensure patient safety and clinical effectiveness.One search focused on elderly patients prescribed oral nonsteroidal anti-inflammatory drugs without a proton pump inhibitor (PPI), unless declined or not tolerated. Of 93 patients identified, 14 were not prescribed a PPI. We reviewed five patient records and found that none had been prescribed a PPI alongside their non-steroidal anti-inflammatory drugs, which was assessed by the GP SPA as a moderate risk. This omission increases the potential for gastrointestinal complications and highlights a gap in adherence to prescribing guidelines.Additionally, one patient’s medication review lacked sufficient detail to support safe and effective ongoing treatment, indicating inconsistencies in clinical documentation. Methotrexate prescribing also did not follow best practice guidance, as the days of the week were not clearly marked on the prescription, a key safety measure to prevent dosing errors. Further searches were conducted on medications requiring monitoring. A search for patients on ACE inhibitors identified 75 out of 567 patients who had not received the required monitoring. Five patient records were reviewed, and all had blood tests completed in August 2025, after the assessment was announcement. Similarly, a review of drugs flagged by the MHRA found that for mirabegron, two out of 36 patients were followed up after the assessment was announced.We also reviewed patients with long-term conditions. A search for asthma patients prescribed two or more courses of rescue steroids identified 23 out of 423 patients. Of the five records reviewed, four patients had been issued a rescue pack.A search for patients with chronic kidney disease stage 4 or 5 who had not been monitored appropriately in the last nine months identified six out of 22 patients. All five records reviewed showed that patients were contacted after the assessment announcement. One patient’s last recorded blood test was in 2019. For patients with hypothyroidism, 21 out of 205 had not received appropriate monitoring within the last 18 months. Five records were reviewed, and all patients had been contacted after the assessment announcement. One patient’s last recorded blood test since 2022. Following the assessment, the provider confirmed that all patients identified have been contacted and remedial actions put in place. Prescribing data from April 2024 to March 2025 showed that the practice did not significantly deviate from the national average in five out of six indicators. However, there was a negative variation in the prescribing of a specific group of antibiotics, with the practice rate at 13% compared to the national average of 7.8%.The provider had conducted a prescribing audit on co-amoxiclav, one of the overprescribed antibiotics, between 2023 and 2025. The audit revealed a 48% increase in prescriptions, from 160 in 2023 to 237 in 2024, with data broken down by prescriber. In response, the provider implemented an action plan that included regular audits, patient education, and targets to maintain a justification rate of over 90% for prescriptions. The audit indicated a positive trend in prescribing justifications between 2024 and 2025; however, overall prescribing volumes increased, and some prescribers continued to demonstrate instances of non-justified use.