The Sidings 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 people were safe and protected from avoidable harm. At our last inspection we rated this key question as Inadequate. At this inspection the rating has changed to Requires Improvement.

At our assessment visit in February 2025 we found patient safety was compromised with a lack of systems, processes, and failure to follow processes at local level. Patients did not always receive personalised, effective care based on research and evidence in a timely way and were exposed to risk. A consistent learning culture was not in place with missed opportunities to improve following incidents and complaints. Staff training was not consistently completed or recorded correctly. Risk assessment findings were not always actioned to mitigate or minimise identified concerns.

This meant that some aspects of the service were not always safe and there was limited assurance about the sustainability of safe practices. There was an increased risk that people could be harmed.

At our visit in April 2025 we found recent changes had led to improvements with more changes planned. The changes had not had time to become part of normal working practice. Sustainability and the effect of the changes on safety could not be assessed during our assessment.

The service was in breach of legal regulations relating to safe care and treatment and governance.

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.

At our first visit in February 2025 the service did not always have a proactive and positive culture of safety based on openness and honesty. The provider had processes in place for staff to report incidents, near misses and safety events to identify learning. However, people did not always feel supported to do so, as the provider had not always listened to concerns about safety and investigated appropriately. People felt they were discriminated against and penalised when they raised concerns about safety and shared ideas to improve, as the primary response was to dismiss or blame individuals.

If staff did report an incident they were not managed in line with providers policy. Delays were seen in local managers reviewing incidents, with no system in place to ensure incidents were reviewed in a manager’s absence. Clinical incidents were not always reviewed and assessed by a clinician. Lessons were not always learnt to continually identify, adopt and embed good practice to improve safety.

There was a system in place to record and investigate complaints. During our assessment the provider confirmed that not all complaints had been added to the reporting system, investigated and managed according to policy. This meant there was no awareness of how many complaints had been received, the content of complaints, learning identified and what action was required.

Representatives from the PPG felt the practice had not always taken concerns seriously and did not proactively make improvements to the service.

At our visit in April 2025 the provider had made changes to the management structure and increased provider oversight. Staff told us this had made positive changes in the safety culture. They told us these changes meant they felt more able to raise concerns and confident they would be listened to without prejudice. A dedicated lead member of staff was now identified as being responsible for managing incidents and learning opportunities with their absences covered by another member in the management team.

The provider had reviewed the complaints received within the practice, identified a backlog and managed the backlog at corporate level. Actions were taken to manage and resolve all outstanding complaints appropriately with patient and staff involvement. We saw evidence in meeting minutes that learning points were identified and shared with staff at practice meetings. A dedicated complaints lead at the practice now manages any complaints locally.

These changes within the practice to improve the learning culture had been shared with the PPG and a PPG member told us these changes had started to improve the care delivery to patients.

The provider was proactive in making some immediate changes when issues were identified and further changes were made following our first visit. We saw evidence that changes had led to improvements, but the changes had not been in place long enough to assess their full impact and ongoing sustainability.

At our visit in February 2025 we found the service did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor peoples’ safety.

Care home staff told us if the care co-ordinator who worked for the Primary Care Network (PCN), a group of GP practices who work together to provide some services to their patients, liaised between the care homes and the practice services users care needs were met and communication was good. If the care homes dealt directly with the practice they described difficulties in securing medical input and communication was said to be poor.

Staff had not always been encouraged and supported to attend PCN meetings or actively engage with the other services within the network to be able to fully engage with the systems and pathways available.

Patient clinical triage to assess urgency of care request, patient appointments, referrals, test results and tasks had not always been planned and managed in a timely way by appropriately qualified staff to ensure safety across care journeys.

For example, the clinical system review showed 259 outstanding letters to be actioned, 452 patients waiting for routine appointments and 152 patients waiting for clinical pharmacist review.

We saw evidence that clinical triage was routinely carried out by a member of the admin team who told us they were not trained, skilled or supported to carry out the task. This meant patient care decisions were potentially unsafe due to lack of clinical input. For example, a decision was made by a non-clinical member of staff to downgrade a task deemed urgent by clinical staff to routine which led to a significant risk to that patient. These changes to the ways of working were not in line with the providers policy and the senior leadership team were not aware these practices had been adopted locally.

During our assessment visit staff told us a large amount of unprocessed paper work was locked in a cupboard and some stored elsewhere in the building. The paperwork was a mixture of consent forms, registration documents and some letters. The provider confirmed they could not be assured that all the paperwork had been managed in line with policy and reviewed or scanned onto the patients record. A random selection of documents was reviewed by the CQC and the provider, all of which had been managed appropriately.

At our visit in April 2025 the provider had made changes to systems and processes.

The provider had instigated meetings to help to improve the working relationships with one care facility and a member of the local management team had met with representatives of other providers to improve shared care for patients.

Staff were now able to attend PCN meetings, with protected time available and were encouraged to engage with other services to encourage learning and development.

The provider introduced new systems related to clinical triage. A duty clinician was now identified daily who carried out clinical triage of patient care needs, review and appropriately manage work flow and care decisions. Staff we spoke with told us clinical triage was now carried out by an appropriately qualified clinician, which was evidenced by auditing of this process.

Changes in the way clinical appointment slots were released and managed had led to improvements. This included the management of referrals, test results and tasks. We saw evidence of this of these improvements on the clinical system. The provider had introduced monitoring of delays using a clinical dashboard to identify any increases in delays and manage this in a proactive way by amending working practice and providing extra support if emerging issues were identified. We reviewed the quality dashboards over a 3 month period and we saw evidence of ongoing improvements.

The provider took action following our inspection to review all unprocessed paper work to assure themselves of patient safety and take action as required, no patient harm was identified. Practices were changed locally to prevent reoccurrence.

The new processes had led to improvements and initial results were positive, but the processes had not been in place long enough to be fully embedded in normal working practices and evidence sustainable improvement.

The service worked with people to understand what being safe meant to them and the best way to achieve that. They concentrated on improving peoples’ 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. All staff had completed appropriate safeguarding training according to their role.

The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations.

A safeguarding administrator was in post and a dedicated safeguarding electronic inbox was in place to receive referrals directly. This ensured all information was reviewed, coded and flagged correctly in a timely way. Examples were given of good practice which had safeguarded patients from harm.

Safeguarding was a standard agenda item on the Clinical Governance Agenda. A multi-disciplinary meeting including primary care, community care and secondary care regarding vulnerable patients occurred in November 2024 and were planned to take place at 3 monthly intervals. Extra discussions with key stakeholders would take place outside these meetings for specific concerns as required.

At our visit in February 2025 we found the service did not always work well with people to understand and manage risks. They did not always provide care to meet peoples’ needs that were safe, supportive and enabled people to do the things that mattered to them.

Individual risks were not always adequately assessed or people were not always appropriately involved in this. For example, patients were not always involved in medicine reviews, medicines monitoring and long term condition reviews were not always completed in a timely manner. People are therefore not always provided with information about how to keep themselves safe.

Staff with appropriate experience were not always involved in finding appropriate solutions following identified risks. For example, clinical incidents and complaints related to clinical care and changes to how appointments were managed did not always involve clinical staff with full understanding of the risks involved and solutions required.

At our visit in April 2025 we found the provider had reviewed the risk management process and took actions to minimise these risks.

A Clinical Work Plan (CWP), which included medicine reviews and long term condition reviews to standardise the process to achieve and maintain compliance was introduced. The CWP had identified dedicated staff responsible to review all patients who require monitoring for medicines taken, long term conditions and medicine reviews. We saw audit evidence at our second visit of improvements in place on the work completed at that time. The CWP however, was not fully implemented at the time of our report, which meant outstanding risks remain.

The changes made by the provider had led to improvements of staff involvement in risk management. Staff told us appropriately skilled and experienced staff were now involved in developing solutions to reduce risk.

The provider had developed a Risk Management Framework and appointed a corporate Risk Manager who will deliver training to the identified local Risk Lead. A Risk Register is now in place. A corporate oversight group is planned which will review and monitor risks with a predetermined high score.

Effective systems were in place for checking and monitoring emergency equipment and medicines. Staff could recognise a deteriorating person and knew the action to take.

The new processes had led to improvements and initial results were positive, but the processes had not been in place long enough to be fully embedded in normal working practices and evidence sustainable improvement.

At our first visit in February 2025 we found the service did not detect and control all potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Contracts were in place to ensure the premises were maintained. Health and Safety risk assessments and audits had been undertaken and risks identified but not all had been addressed with appropriate actions at the time of our assessment visit.

Identified risks from the most recent Fire Risk Assessment dated September 2024 had not all been addressed with actions taken at the time of our assessment.

An external company competed a Legionella risk assessment in September 2024. Actions had not been completed at the time of our assessment. The water temperatures were monitored by staff. Hot water temperatures outside the safe range were recorded in January 2025 with no action taken.

Areas within the premises had been upgraded since our previous inspection in 2024 whilst some areas were still in need of refurbishment. The provider was in discussion with the landlord to expedite the required works.

There was no evidence a hard wire electrical check had been undertaken in the previous 5 years. Electrical equipment had been calibrated and tested.

We were told by staff that not all clinical rooms were locked meaning sharps bins, needles and equipment in the room were accessible to all and open to abuse.

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

At our visit in April 2025 the provider had responded and made changes to the processes in place.

The provider contacted the companies who had undertaken the risk assessments and completed or scheduled the required actions during our assessment.

For example: staff had completed fire and fire warden training and fire safety checks where completed weekly. Plans are in place to undertake fire drills on a quarterly basis; we saw evidence the first one had been undertaken before our assessment visit.

Actions were planned to address the concerns from the legionella assessment and the heating boiler was due to be replaced following our visit.

Changes made had improved the safety of the environment but some concerns remained. The improvements could not be fully assessed as they had not been in place long enough to become part of normal working practice and sustainability could not be evidenced.

At our visit in February 2025 we found the service did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met peoples’ individual needs.

Retention of staff had been an issue leaving gaps in staff numbers and experience. The provider had not been aware of the implications on patient care and staff wellbeing prior to our assessment.

The provider did not have a process in place to review staff exit interviews when completed by staff leaving employment. This meant identification of themes related to staff retention had not been identified.

Staff training was not monitored correctly or always completed in line with the providers policy. Protected time for staff training had been removed by local managers and staff told us they were expected to complete in their own time if they could not fit it into the normal working day. This meant staff training completion was not at the expected level.

Staff told us they had been asked to carry out tasks they were not trained or had the necessary skills to do with either no or outdated protocols or pathways in place to follow.

Administration staff were carrying out tasks they were not appropriately trained, skilled or supported to complete by the local management team. For example, they routinely carried out clinical triage and were asked downgrade clinical tasks. This led to increased risk to patients. Staff told us they did not feel able to challenge these decisions with local managers.

At our visit in April 2025 the provider had made changes within the practice which we saw had led to improvements.

The provider had carried out a capacity and demand review, linking directly to increased patient numbers and historic demand at the practice. This identified significant staffing deficits in all areas. Recruitment had taken place or was underway for vacant posts and the provider had decided to over establish funded posts in some staffing areas.

Permanent funding was being sought for other identified gaps to increase staffing and to allow some temporary posts to be made permanent. Ongoing monitoring of staffing and capacity and demand was part of the monthly monitoring dashboard and reported up to providers governance meeting.

A new process had been implemented to review exit interviews by managers. Monitoring of staff retention and themes related to reasons for staff leaving are now reviewed at the providers monthly governance meetings to identify concerns.

Changes to the way staff training was monitored had occurred and we saw evidence that this was now accurate with staff confirming completion. Protected time for staff training had been reintroduced so all staff could complete the required learning, we saw evidence completion rates had increased. Staff told us they were no longer carrying our tasks they had not been trained or had the necessary skills to complete and if they were asked to do so would now challenge such requests and not complete them.

Whilst changes made had improved safety and the effectiveness of staff, the improvements could not be fully assessed as they had not been in place long enough to become part of normal working practice. Sustainability and the impact on patient care could not be evidenced.

Staff skills had been improved by increasing the number of staff able to perform tasks to provide cover and continuity during any staff absence. This led to improved patient care and decreased the risks associated with delays.

Changes made had improved safety and the effectiveness of staff. The improvements could not be fully assessed as they had not been in place long enough to become part of normal working practice and sustainability and the impact on patient care could not be evidenced.

During our visit in February 2025 we saw an effective approach to assessing and managing the risk of infection, which was mostly in line with current relevant national guidance and standards.

People are protected as much as possible from the risk of infection because premises and equipment were kept appropriately clean and hygienic. We saw recent improvements in the maintenance of the fabric of the building which had been carried out by the provider. Further remedial work is required to the fabric of the building which the provider is unable to complete without landlord involvement. The provider has ongoing discussion in progress with the landlord to address these issues.

The practice had a designated infection, prevention and control (IPC) lead.

Cleaning was carried out by an independent cleaning company; a service level agreement was in place and cleaning schedules were in place, followed and monitored by both the cleaning company and the IPC lead.

The cleaning company carried out monthly audits which were not in line with the national cleaning audits and the cleanliness scores did not match with the audits carried out by IPC lead within the practice.

Risk assessments were in place and actions taken to mitigate risks.

Not all staff had undertaken appropriate IPC training.

Information about the risk of infection is shared appropriately with relevant partners, including agencies, people using the service and visitors.

At our visit in April 2023 we saw liaison between the cleaning company and the IPC lead had resolved the aforementioned concerns relating to audit consistency.

All staff had received appropriate IPC training.

During our visit in February 2025 we found peoples’ medicines were not always reviewed to ensure they were safe from the risks associated with them. Medicines Healthcare Regulatory Agency (MHRA) safety alerts were not always actioned appropriately or routinely re run to ensure all patients including newly registered ones had received safe and appropriate medication and monitoring.

Patients prescribed medicines were not always effectively monitored in line with national guidance to ensure continued safe prescribing or identify potential side effects.

For example, during our search of the clinical system we found:

Not all patients taking a medicine for immune system disorders had their records updated to indicate they had been monitored in line with national guidance by an alternative provider. Prescriptions did not always indicate the day of the week the patient should take the weekly medicine to avoid unintentional overdose.

Not all patient on a medication for heart rhythm disorders had been monitored in line with national guidance.

Patients prescribed medication to thin the blood had not all been monitored in line with National Guidance.

Patients prescribed a combination of medicines to manage high blood pressure had not all been monitored in line with national guidance.

Repeat prescription lists were not always updated after receiving hospital correspondence informing of changes to medicines. We identified examples where dosages had not been updated or medicines removed or not started.

Our record reviews indicated that medicine reviews were not always comprehensive and they had not always involved patients and fully considered their needs. Documented evidence did not always indicate what medications had been reviewed, patient involvement and whether appropriate monitoring had been undertaken or reviewed if medications were optimised to reflect patients’ medical needs.

We found 12 patients who had an irregular heart beat who had not been identified as requiring further medication to reduce their risk of stroke during medication reviews.

The issues identified above meant the practice could not be confident the prescribed medication was appropriate and safe. Patients could be at increased risk of known side effects and significant harm.

A decision had been taken by local managers in relation to the legal requirements of FP10 paper prescription. A log to monitor usage and track the FP10s had been removed leaving the potential that the documents could be open to abuse and misuse. The decision was made without clinical input and was outside the legal requirements. This was identified by the nursing team and the situation was resolved.

The provider took immediate action to improve safety and reduce patient risk. Identified patients were contacted and their care was reviewed with actions taken as required.

At our visit in April 2025 we saw audit outcomes that evidenced improvements in medicine optimisation following changes made and the implementation of the CWP following our visit in February 2025. The work was ongoing at the time of our report to sustainably improve medicines management and reduce risk.

The process in place to manage MHRA alerts had been reviewed and amended to improve actions taken and now included regular re-running of historic alerts.

The improvements could not be fully assessed as the actions had either not been implemented at that time or in place long enough to become part of normal working practice. Sustainability and impact on patient care could not be evidenced.

.