Ravenscroft 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 service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Score: 2

The service did not always have a proactive and positive culture of safety based on openness and honesty. They did not always listen to concerns about safety and did not always investigate and report safety events. Events were being discussed in meetings however this was recorded in a confusing way.

We identified some risks that had been overlooked. The service had a significant event and complaints policy and log. There were processes for reporting, recording and acting on incidents and staff carried out significant event analysis (SEA). Staff told us they could raise concerns and report when things went wrong. Staff told us that incidents were discussed during team meetings, however some staff reported that the learning outcomes were not always shared with staff. From our review of clinical meeting minutes, it did not appear that significant events or safeguarding was a standing agenda item for discussion. From the evidence provided, it shows that incidents were discussed in meetings but it was not clear what the incidents were or when they occurred, if these had been flagged as safeguarding or a significant event, and there were no clearly documented actions for follow up. Whole team meeting minutes reviewed from September 2024 showed no evidence of complaints or significant events being discussed.

The practice had received nine written complaints in the 12 months leading up to the assessment, of which eight were upheld. From information we reviewed, we saw that the service had investigated complaints and recorded any actions taken. However, we identified that there was only documented learning from two complaints received.

The practice had documented nine significant events in the 12 months leading up to the assessment. It was unclear if the significant events log was being completed accurately as the events recorded were not discussed at the clinical meeting following the event but were discussed at the last clinical meeting before the CQC assessment. There was a column on the significant events log named ‘discussed collectively’. This showed that only two of the nine events had been discussed and documented.

Staff felt there was an open culture, and that safety was a priority. The provider had processes for staff to report incidents.

We asked the provider to place a link on their website to the Give Feedback on Care process so we could hear of patients’ experiences of care.We received only two pieces of feedback, both of which were positive. Leaders told us that there was a Patient Participation Group in place, consisting of eight members, but that participation varied, and it was a challenge to get patients involved.

Score: 2

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 people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

Our review of patients’ records and the clinical system indicated that clinical letters and recall systems were not always managed and responded to safely, for example, we identified an instance where a patient had not been reviewed following an attendance at accident and emergency (AE), a patient still on a register and receiving treatment for a condition they no longer had, and a patient needing a change in treatment following testing that had not been actioned. The provider could not demonstrate that all communication was reviewed and acted on appropriately.

There was a system to ensure referrals to specialist services were documented and contained the required information. The practice had processes in place to monitor urgent (two week wait) referrals that had been made. There were some safety netting processes in place to ensure patients were followed up, for example. Referrals and test results were managed in a timely way.

Score: 2

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, however gaps were identified in systems and processes, and safeguarding training was not in line with current guidance.

The practice had a lead for safeguarding adults and children, however, some processes to make sure people were protected from abuse and neglect required improvement, for example, the safeguarding lead could not confirm during assessment how often the safeguarding register was reviewed and when asked if children who were not vaccinated were routinely discussed at clinical meetings as a safeguarding concern, staff were unsure. The practice maintained a list of vulnerable people and acted on concerns.

We found evidence of safeguarding and other incidents being discussed in meetings but it was unclear as to what the event was and when it took place.

The management team had some safeguarding systems and processes in place, these were up to date and in line with local guidance. All staff we spoke with were aware of who the lead was and how to escalate any concerns they had. Staff told us that there was a separate phone line for social services to contact the practice, allowing them to bypass the main practice phone line.

Information on the local safeguarding processes and who to contact was available to staff should they have a concern. However, training records provided showed not all staff had received safeguarding training to the appropriate level. For example, our review of safeguarding training identified gaps in safeguarding children training across both clinical and non-clinical staff, and where it had been completed, it had only been completed to level 1. We also identified gaps in adult safeguarding training with non-clinical staff only having completed level 1 of the training and 1 member of clinical staff also having only completed level 1 of the training. This was not in line with intercollegiate guidance. All staff we spoke with said they were confident about raising any concerns and knew who to report any safeguarding concern to.

We saw that Disclosure and Barring Service (DBS) checks were undertaken for all staff, in line with the practice policy. DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable.

The service worked with people to understand and manage risks enabling them to make informed decisions. The Primary Care Network Pharmacist that works within the practice was responsible for the management of safety alerts. Alerts were managed and responded to appropriately. During this assessment, we found that not all safety alerts were being adhered to, and searches were not being run in a timely manner, putting patients at potential risk.

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

The practice was equipped to deal with medical emergencies (including suspected sepsis) and staff were suitably trained in emergency procedures. We did not see guidance, including visual tools available to enable staff, including reception staff to identify a deteriorating patient on reception during the assessment, however leaders told us that they did have them and would locate them and return them to reception following the assessment which we have received confirmation of.

Score: 3

The service detected and controlled 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 maintained. Health and safety risk assessments and audits had been undertaken and risks identified had been addressed. There was a business continuity plan in place.

The practice was spread over 3 floors of an older listed building leased from a landlord. The provider had responsibility for maintenance of the area occupied by the service. Clinical rooms we observed during assessment were carpeted and taps were not lever operated, leaders told us that they had communicated with the landlord about changes but that the landlord was resistant. The provider told us they used the services of a private cleaning company who cleaned the practice daily and we saw evidence of a cleaning schedule.

Records reviewed showed that all staff had completed both fire safety and fire warden training in addition to electrical safety training. There was a fire evacuation floor plan of the premises available, and fire extinguisher checks were up to date.

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.The practice submitted a human resources spreadsheet for all staff, which included the required checks to ensure safe recruitment. Safe recruitment practices were followed.

There were a range of clinical and non-clinical roles within the practice. We found training was up to date, learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence. Safe recruitment practices were followed.There was a supervision policy in place last reviewed in March 2025 and leaders were able to describe systems for supervision of new starters.

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

The practice had a designated infection, prevention and control lead (IPC), the training matrix provided showed that the IPC lead and practice staff completed the required training.

Staff told us they were responsible for wiping down surfaces and equipment in the consultation rooms in between patients. The clinical rooms had the necessary equipment for patient examination and disposable curtains were replaced 6 monthly. Cleaning schedules were in place and followed. Staff told us they had a good relationship with the cleaning staff, and they were able to raise concerns with them about the quality of cleaning. Risk assessments and audits were completed, and actions taken to mitigate risks.

Score: 2

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Leaders had not established processes to ensure all those prescribed medicines with specific risks received recommended monitoring prior to prescribing.

The practice had not always responded appropriately to drug safety alerts and searches were not being routinely run on historical alerts to identify if there were any remaining or emerging risks. The practice policy stated that it was the task of the Primary Care Network (PCN) pharmacist linked to the practice to run and action searches for the alerts, however it did not detail when and how often searches should be run for previous and historical patient safety alerts and we saw no evidence of a practice led initiative to review historical alerts. The service submitted evidence of a PCN created document of patient safety alerts for 2025 of which 2 needed actioning.

People’s medicines were not always appropriately prescribed, supplied and administered in line with the relevant legislation or current national guidance. We found some staff had not always followed the prescribing policy to ensure they prescribed all medicines safely.

As part of our assessment a number of set clinical record searches were undertaken by a CQC GP specialist advisor. These searches were visible to the practice.

We looked at a sample of patients on high-risk medicines andwith long term conditions and found clinicians had not always checked the patient had the required monitoring tests and recorded the results into the patient record system. Most medicines were being prescribed safely; however, we noted that not all prescribed medicines were being monitored in line with national guidelines. For example,

• Patients prescribed ACE inhibitors or Angiotensin II receptor blockers (ACEI and ARB) used the treat raised blood pressure, heart failure and some patients with chronic kidney disease, had not received the required monitoring. Of the 24 patients identified as not having received the required monitoring, we further reviewed four patients and found that for all of these patients, the medicine review date exceeded the date for when monitoring would have been due, posing a potential risk. Also, the medicine reviews lacked detail and did not identify when blood pressure was high or a review of the types of medicines being prescribed.
• Three separate clinical staff had not identified that a patient on long term medicines for the treatment of diabetes needed a review of medicines following monitoring.

• Records searches identified eight patients as having a potential missed diagnosis of diabetes. Where appropriate, repeat monitoring was not carried out within the required timeframe as specified in guidance. One patient had not been correctly coded meaning the potential risk for missed monitoring was high.

• Records searches identified 54 patients as having a potential missed diagnosis of chronic kidney disease (CKD) stage 3, 4 or 5.

• Elderly patients on oral non-steroidal anti-inflammatory drugs (NSAID) over 65 years or antiplatelet over 75 years and no proton pump inhibitors (PPI): of the 36 patients identified from this search, we further reviewed three patients and found no evidence that the related alert was being adhered to and a review of medicines had taken place to identify and monitor potential risks.

• We reviewed a sample of patients 159 with asthma and found six patients who had been prescribed two or more courses of rescue steroids in the last 12 months and had not had the required monitoring.

• Two out of 23 patients were identified as having CKD stages 4 or 5 who had not had the required monitoring in the last nine months.

• We reviewed a sample of 212 patients with hypothyroidism who had not had the required monitoring for 18 months and found four patients of concern.

• In line with NICE guidance our search identified 29 out of 280 patients with diabetes whose latest HbA1c readings was over 75mmol (HbA1c > 75). The service could not demonstrate that these patients received appropriate follow-up and support. Patients were not being reviewed holistically to address other health concerns that could exacerbate their condition, such as diet, cholesterol and blood pressure.

• We reviewed a sample of patients prescribed a disease-modifying antirheumatic drug (DMARDS) and found that these patients were being adequately monitored.

We saw some evidence that patients were being sent text reminders to ask them to come in for monitoring, but staff often didn’t act when patients didn’t respond. It was unclear as to whether alternative methods of communication were tried, and medication quantities adjusted to prevent potential harm. We raised these concerns with leaders. The GP partners agreed that not all staff were properly checking that monitoring was up to date and that it was safe to issue a prescription.

Following our assessment, leaders took action to review all concerns highlighted to them and provide updated monitoring information for those patients. All patients had received either a phone call or text message inviting them into the practice for monitoring, with some patients having attended the practice and some not responding.

Leaders also told us they had put in place systems to strengthen recall processes and had reviewed their repeat prescribing policy to ensure gaps in monitoring were identified and actioned.

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, including emergency medicines and vaccines. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments.

Antibiotic prescribing data reviewed as part of our assessment showed the practice was largely in line with local and national averages. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.