Old Road 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 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.

Improvements had been made in response to the breach of regulation 12 (Ensure care and treatment is provided in a safe way to patients) issued to the practice at the previous assessment. These improvements included environment safety, risk assessment safety, infection control, and medicines management. These improvements were recent changes and needed to be embedded at the practice for assurance.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice had developed an action plan to improve safety since the last assessment; this was based on developing a learning culture. They listened to concerns about safety, investigated, and reported safety events. Lessons were learnt to identify good practice; however, this was a recent change and had not been fully embedded at the practice.

Leaders at the practice encouraged staff to raise concerns when things went wrong. People felt they could raise concerns and did not fear retribution. Staff told us concerns and actions were discussed in their weekly huddle meetings. However, notes taken at staff meetings did not always evidence this clearly.

The practice had processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints, and when things went wrong. We saw staff apologised where appropriate and gave people support for a positive outcome. Learning from incidents and complaints seen, resulted in changes that improved care for others. For example, following complaints from people who could not use the online appointment booking system, a process was initiated for receptionists to support people to book an appointment and explain to them the triage process.

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

We received positive feedback from people relating to the management of test results and timely, appropriate referrals. Care home representatives confirmed people who had recently moved into a care home were able to register easily with the practice and had received a health check by a clinician in a timely manner. People had access via the practice website to self-referral forms to services.

There were systems in place to process information for people registering at the practice, which included for example homeless people and temporary residents.

The staff described a manageable backlog of new people’s records which required summarising.

Staff told us they had access to the information they needed to deliver safe care and treatment.

A new artificial intelligence (AI) system had been introduced recently; this had halved the workflow backlog since the last assessment and was seen to be working effectively. The practice audited the AI system for assurance it was working effectively and appropriately. The new system managed the flow of work within the practice including for example, how results for a range of tests were reviewed and filed. People’s correspondence was prioritised for urgency, for example scan results and ambulance reports. Procedures were in place to ensure any required actions were reviewed and authorised by an appropriate clinician. Test results were managed where possible by the requesting clinician or the duty GP to ensure that when a clinical colleague took leave, their tasks were appropriately delegated and acted on. We saw tests results at the time of our assessment were cleared each day.

The practice had a process to ensure cervical cytology results were received and acted on.

The practice worked with other providers to deliver shared care including when people moved between services.

The practice protected peoples’ right to live safely, free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect. The practice shared concerns appropriately. People we spoke with had no specific views or concerns in this area.

Staff told us they had received training in safeguarding children and adults, were confident to report any concerns and knew who the safeguarding leads were at the practice. Safeguarding policies were in place and known to staff.

The practice maintained a list of vulnerable people to enable them to act on concerns and work in partnership with other organisations. The practice held meetings where safeguarding was discussed. We reviewed the meeting minutes and saw people’s needs were discussed however, documentation of actions in the notes was a recent change and practice should continue to embed this at the practice.

Arrangements were in place to follow up vulnerable people who had not attended for a healthcare appointment, this included for example, post-natal, and secondary care appointments for children and vulnerable adults.

People told us staff worked with them to understand and manage risks. Staff provided care to meet people’s needs ensuring they were safe and supported, and documented things that mattered to them.

People who provided feedback for this assessment had no specific views or concerns in this area.Care home representatives told us practice clinicians involved people, their carer’s, and family appropriately to ensure care and treatment met individuals’ needs and preferences.

Staff confirmed they had guidance to identify, assess, and manage people whose health was deteriorating, and to manage medical emergencies. Staff we spoke with told us they could recognise people whose health was deteriorating and knew the action to take. The practice had a duty GP who was available for advice and support when necessary.

Following the findings at the last assessment, the practice had developed risk assessments and a monitoring process to ensure the environment was safe. Arrangements were in place to keep the practice premises well maintained. We saw potential risks were monitored in the practice environment and actions needed had been addressed. The equipment, facilities and technology at the practice supported the delivery of safe care. People who provided feedback at this assessment told us they felt safe receiving their care and treatment and had no concerns about the practice environment safety.Ongoing checks relating to fire safety, electrical safety and equipment calibration had been completed. However, the improvement made to document these checks and monitoring was a recent change and should continue to be embedded at the practice.

The practice had a business continuity plan which identified a range of risks and how they would be managed.

During the onsite assessment, we observed fire exits were clear and fire safety equipment was available and had been checked.

The practice used technology securely and effectively with random monitoring checks for assurance and conformed to the relevant digital and information security standards with arrangements in place for the confidentiality of data management.

We followed up on the findings at the last assessment, where there were no appraisals, support, supervision, or competency checks documented, and the practice was unsure if they had the right number or skill mix of staff. At the time of this assessment there were enough qualified, skilled, and experienced staff, they received support, clinical supervision, competency checks and their development was recorded in their records. Staff told us they worked well together as a team to provide safe care that met people’s individual needs.

There was a process in place to monitor and audit the required learning for staff, this ensured people were supported by staff who were trained to meet their needs safely and effectively.

Feedback from people and representatives from care homes was positive about the knowledge of clinical staff and the clinical care provided by the practice.

The practice had systems and processes for the safe recruitment of staff. Staff personnel files held appropriate recruitment checks. DBS checks were in place for all staff who required them for their role and a risk assessment for roles had been carried out. We received assurance that the professional registration of clinical staff was checked at recruitment and on an ongoing basis. All new staff received an induction programme that was tailored to their role.

New staff members told us they had received an effective induction programme and felt supported by leaders and colleagues in their new role. Staff told us they had received sufficient training, and we saw evidence of competency checks and clinical oversight of their work, with recent appraisals that had been undertaken.

Many of these processes were new and should continue to be embedded at the practice.

We followed up on the findings at the last assessment regarding the management of risk of infection. At this assessment, the outstanding actions from the previous infection prevention and control (IPC) audit that had been carried out by the local Integrated Care Board (ICB) on 31 July 2024 had been addressed and completed. The ICB audit for 2025 was being carried out at the time of this assessment and the practice had not received the report.

We observed appropriate processes and procedures in place at the practice to assess and manage the risk of infection. Feedback we received from people at the time of this assessment was positive in respect of the cleanliness of the practice environment. The practice had an updated policy and a lead nurse, for infection, prevention, and control (IPC). The IPC lead carried out regular monitoring, audits, IPC staff training, and attended update meetings. The IPC lead had support from a GP Partner for clinical support and advice.

At the time of this assessment, we observed the practice to be clean and tidy. We saw documented checks of cleaning and arrangements to effectively communicate with cleaners to resolve any issues. There were records of equipment cleaning and appropriate arrangements to manage clinical waste in place.

Policies and guidance were available for staff, and they had completed training relevant to their role. Staff told us they had no IPC concerns and about the systems in place for safely dealing with clinical specimens and spilt bodily fluids.

We received assurance of the legionella checks that had taken place and the monthly handwashing audits carried out to ensure staff followed safe practices. These processes were new and should be continued to embed at the practice.

The practice had systems in place to support the safe and effective use of medicines. The practice ensured medicines and treatments were safe, and met people’s needs, capacities, and preferences. They involved people in planning, this included when changes happened.

Medicines were stored securely in locked cabinets, and prescription stationery was tracked using serial numbers and logs. Unused prescription forms were destroyed securely, with oversight from the practice manager. Fridge and ambient room temperatures were monitored daily at the main site. However, emergency medicines at the branch site were not subject to temperature monitoring before this assessment. This was raised with the provider and acted on during the onsite assessment. Staff described a clear process for responding to temperature control for medicine, including escalation, quarantine, and the use of a data logger to capture accurate information about any deviations.

Emergency equipment such as defibrillators and oxygen cylinders were available and routinely checked. Expiry dates of emergency medicines were recorded, and at the time of this assessment all appropriate strengths of adrenaline were available at both sites, in line with best practice. This addressed a concern highlighted at the previous assessment.

We received positive feedback from 2 people in relation to medicines management during the onsite assessment who told us they were regularly called into the practice to have their medicine reviewed. The care home representatives told us the repeat ordering process worked well, people’s medicines were regularly reviewed, and staff answered and dealt with any queries effectively.

Repeat prescribing was supported by standard operating procedures and by a pharmacist from the primary care network (PCN). Staff were clear about the escalation process for urgent reviews. The practice maintained a log of medicine shortages and liaised with local pharmacies to source suitable alternatives. Discharge summaries were reconciled promptly and uploaded to the clinical system, ensuring timely actions when other providers changed medicines.

Patient Group Directions (PGDs) were in place, up to date, and authorised by the clinical lead GP. Nurses were appropriately authorised to administer medicines under PGD’s. Staff also described designated lead roles among nurses, covering areas such as diabetes, respiratory care, infection prevention and control, and palliative care. The practice used computer software to support medicines management and patient communication.

The practice received safety alerts from the Medicines and Healthcare products Regulatory Agency (MHRA) and stored them in a central folder; however, there was no documentation of actions needed. Although the practice was acting on alerts this could not be evidenced. The practice immediately changed their process and added the date an action had been taken to manage alerts and sent us the backdated evidence for assurance this work had been completed. This improvement was a recent change and should be continued to embed at the practice.

A Care Quality Commission GP Specialist Advisor undertook remote searches of the practice patient records. Clinical searches identified 19 people prescribed medicines in a combination subject to a patient safety alert issued in 2016. Of 5 records reviewed, 4 people had not been informed of the risks, and one had not been requested to complete appropriate blood monitoring. 4 people were only asked to have blood tests recently in August 2025, despite the alert being longstanding. At the time of the site assessment, we were given assurance these people had received their blood monitoring and an audit process set up for the future.

Methotrexate prescribing was monitored appropriately. However, both records we reviewed did not specify the day of the week the medicine should be taken. Methotrexate should be taken once weekly and must be prescribed with the day clearly stated to minimise the risk of dosing errors. Following our onsite assessment, we received assurance this had been changed on patient records and the template used to monitor people receiving this medicine to include recording the day of the week the medicine was taken.

Non-steroidal anti-inflammatory drugs (NSAIDs, used to reduce pain, fever, and inflammation) prescribed to people aged over 65 years, and antiplatelet medicines (used to reduce the risk of blood clots) prescribed to people over 75 years were also reviewed. Clinical searches identified 64 people in these groups who had not been prescribed a proton pump inhibitor (PPI). PPIs reduce stomach acid and are recommended in National Institute for Health and Care Excellence (NICE) guidance to lower the risk of gastrointestinal bleeding in people taking NSAIDs or antiplatelets. Of the 5 records reviewed, 2 people had not been prescribed a PPI, and it was noted they had not declined this treatment, furthermore there was no documented reason the medicine had not been offered. Following our site assessment, we received assurance that people had been contacted, and a PPI offered. Changes on people’s records and the template used to monitor people been updated.

The clinical searches also identified 8 people with stage 4/5 chronic kidney disease. Of these, we reviewed 5 records. 3 people were under the care of a renal clinic, but 2 were managed by the practice. These 2 people had not received blood monitoring within the recommended time of 6–9 months. This placed both people at increased risk of avoidable harm. Following our onsite assessment, we received assurance that people had had been offered the blood monitoring and the template used to monitor these people had been updated.

Staff were aware of gaps in clinical management and had worked to address them, following the remote searches and onsite assessment. They described person-centred approaches to medicines management, including follow-ups for inhaler use, monitoring for side effects, and combining reviews to reduce unnecessary appointments

We reviewed a range of prescribing indicators, which included for example, antimicrobials, antipsychotics, and antibiotics. The practice indicators were outside the expected range for these medicines however, showed improvement over the last year against national expected statistical data. However, there was no program of regular clinical audits to understand prescribing and focus on improving prescribing habits, care, or treatment at the practice. We were told this was an area for the future that the practice would add to their regular audits.

Many of these audits, and reporting processes were new and should continue to be embedded at the practice.