Clay Cross 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. This key question has been rated as Requires improvement.

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 had a culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Staff were aware of the process to raise significant events and complaints. The Patient Participation Group (PPG) felt the provider took concerns seriously and made improvements to the service, for example a new telephone system to improve access to the practice.

However, feedback from staff showed that approximately half of the staff were not made aware of learning from significant events. The provider informed us that learning from significant events was discussed at clinical meetings. We reviewed the minutes from clinical meetings and found that a recent significant event regarding a cold chain breach had not been recorded in the clinical meeting minutes. Most staff could not recall any learning shared with them following a significant event. Most members of staff told us that learning from complaints was not shared with them. We reviewed minutes from clinical meetings and found that complaints were not a standard agenda item. Systems to identify trends in complaints and significant events were not in place to monitor if improvements implemented had been effective.

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, including when people moved between different services. Feedback from 2 care homes was very positive regarding the way the practice worked with them. There were systems in place for summarising the records of new patients.

We found 1,152 open documents dating back to 2023 in the practice’s IT system. This included letters from secondary care and safeguarding concerns. We reviewed a sample between 2023 to 2025 and found they had been processed but the workflow had not been closed down. We found many documents had been sent to the same person multiple times by different people. Due to time constraints the person receiving them had dealt with the issue once but left the others open. We found that 578 of these documents had not been coded meaning staff may not have access to the most up to date patient information. The provider acknowledged that systems to close the workflow down needed to be improved. We asked the provider to send us evidence that this had been completed however they did not provide this.

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 practice maintained a list of vulnerable people and children and acted on concerns working in partnership with the wider multidisciplinary team. Safeguarding policies were in place and known to staff. Alerts were added to the records of vulnerable adults and children with a known safeguarding concern. There were systems in place to follow up children that were frequent attenders to AE and children who failed to attend for childhood immunisations.

The service worked with people to understand and manage risks. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Most of the required emergency equipment was available and maintained. However, a suction machine was not available and a risk assessment to mitigate potential risks had not been completed. Whilst most of the recommended emergency medicines were available, pain relief was not and a risk assessment to mitigate potential risks had not been completed. Most of the emergency equipment was available however, suction was not.

The service made sure equipment and technology supported the delivery of safe care. Contracts were in place to ensure the premises were mostly maintained. There was a business continuity plan in place which was monitored and reviewed.

However, the service did not always detect and control potential risks in the care environment. At both the main and branch practices risk assessments were not in place for the storage of oxygen. Fire risk assessments had not been completed since June 2022 despite a recommendation in the risk assessments that they should be repeated annually. At the branch practice we found that fire drills had not been carried out, a legionella risk assessment had not been completed and a gas safety assessment had not been completed since November 2022. The Health and Safety Executive (HSE) mandates annual gas safety checks.

The service did not always make sure there were enough qualified, skilled and experienced staff, this had been further impacted by high staff sickness levels. Staff told us there were enough staff when people were not off sick. Staff felt frustrated and stressed that staffing levels were not appropriate. They told us this meant they could not always offer appointments as needed. During our assessment, we found that there were not enough staff to keep on top of the coding. Some staff groups reported they were treated differently and there was not always equally between non-clinical and clinical staff groups. For example, clinical meetings were held for clinical staff but meetings for non-clinical staff had not been held for a long time. which negatively impacted communication.

The service did not always make sure staff received effective support, supervision and development. For example, systems for auditing the prescribing of non-medical prescriber’s consultations and prescribing had not been completed and regular clinical supervision was not in place.

Safe recruitment practices were not always followed. In particular, satisfactory evidence of conduct, a full employment history and satisfactory information about any physical or mental health conditions which were relevant to a person’s ability to carry out their role. Up to date staff immunisations were not always recorded and risk assessments to mitigate potential risks were not in place. In particular, tetanus, diphtheria, polio, measles mumps and rubella (MMR) and hepatitis B.

Staff received annual appraisals and training was mostly up to date. However, some staff had not completed training for people with autism or a learning disability. Some receptionists and practice nurses had not completed safeguarding training at a level appropriate to their role. The provider was unable to evidence that locum and salaried GPs had completed all of the recommended training.

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 practice had a designated infection, prevention and control (IPC) lead and most staff had received relevant training. Cleaning schedules were in place and followed. Nursing staff completed cleaning schedules for the cleaning of medical equipment. IPC risk assessments and audits were completed, and actions taken to mitigate risks. For example, carpets in the waiting room.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

We found that potentially 150 out of 207 people prescribed medicines used to prevent blood clots had not had the required calculation to monitor their kidney function. Of the 5 records sampled, 4 people were overdue monitoring. Following our assessment, the provider sent us evidence that this had been completed.

National prescribing data showed the practice was a high prescriber of medicines used in the management of nerve pain. We found that potentially 76 out of 337 people prescribed these medicines had not had a medication review or their dose reviewed in the last year. Of the 5 records sampled, 4 people were overdue monitoring. Following our assessment the provider sent us an action plan detailing how they would address this issue.

Systems were in place to manage and respond to safety alerts and medicine recalls. We found that a small number of people, prescribed a medicine used in the treatment of an overactive bladder had not had their blood pressure monitored in line with national alerts. Following our assessment, the provider sent us evidence that this had been completed.

Nursing staff had the appropriate authorisations to administer medicines (Patient Group Directions) which were appropriately signed, dated and authorised. However, the appropriate authorisations to administer medicines under Patient Specific Directions (PSDs) were not always in place. We found evidence that vitamin B12 injections had been given with no PSD in place meaning the patient had not been appropriately assessed by a prescribing clinician before the injection was administered. The provider was aware PSDs were not always in place and had started to address this.

Prescription stationery was stored securely. However, the system in place for tracking prescription stationery throughout the practice was not effective.

Medicine reviews were appropriate and well-structured. Systems were effective in monitoring people prescribed medicines used in the treatment of rheumatoid arthritis. Effective systems were in place for the management of vaccines.