Uni-City 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 practice since its new registration with CQC. This key question has been rated as Inadequate The practice was in breach of the legal regulations in relation to safe care and treatment, staffing and fit and proper persons employed.

This service scored 31 (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 did not have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice. Learning events were not collated to enable analysis of trends and discussions at clinical meetings. The clinical meetings minutes for this year did not contain evidence of discussions about significant events and any learning from these. Staff meeting minutes did not have evidence to demonstrate any discussion or shared learning with the team had taken place and staff feedback reflected this. Staff expressed a desire for more transparent and action-oriented meetings.

The service did not work well with people and health system partners to establish and maintain safe systems of care. The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services. There were systems in place for processing information relating to new patients, however the practice had a back-log of summarisation records due to lack of oversight. Referrals and test results were not managed in a timely way. For example, there were 74 pathology test results to be reviewed, holding both normal and abnormal results. The oldest of which dated back to the 10 December 2024. The provider informed us these would be reviewed with immediate effect. Clinical meetings were attended by a broad range of clinicians and held monthly.

The service did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. Safeguarding policies were in place and known to staff however staff training records showed that not all staff were appropriately up to date with their training in relation to safeguarding. The practice held a list of vulnerable people, however the list was not being effectively maintained. This was confirmed when it was noted during the inspection that there were 64 patients identified on the child safeguarding register, however only 2 patients were then confirmed to be appropriately listed, the remaining patients were out of scope due to their age. During the inspection, we checked a sample of do not attempt cardiopulmonary resuscitation (DNACPR) records for patients. The service was also not able to provide evidence of an effective system to ensure DNACPR records remained up to date and relevant. However, the practice was active within their Primary Care Network, attending and contributing to meetings. The provider made sure children had been appropriately followed up with when they failed to attend appointments with primary or secondary care services.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.There were systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment. We identified processes to monitor delays in referrals and the practice carried out audits to ensure ‘two weeks wait’ (2WW) cancer referrals had been booked with secondary care providers as a safety netting mechanism (2WW cancer referrals are urgent referrals used to investigate symptoms to detect cancer).

The practice did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. For example, the practice had evacuation chairs on both floors in the event of a fire, however, staff had not been trained in how to use these. There were no risk assessments in place to mitigate this. Staff could recognise a deteriorating patient and knew what action to take, however, it was noted during our on-site visit, there were patient waiting rooms on 2 floors. Leaders told us that CCTV was in place to aid monitoring of these areas but this was not constantly monitored, and although clinicians were in the rooms around the waiting areas, they would only be able to identify an issue in between their appointments.There was no risk assessment in place for these areas, should patients experience deterioration while waiting for their appointment. Since the inspection, the provider has added new arrangements for staff to perform to ensure patients are checked regularly while awaiting an appointment in these areaHowever, maintenance contracts were in placed to maintain the accuracy of equipment (calibration), scheduled safety checks were conducted on the fire alarm system, emergency lighting and equipment. Health and safety risk assessments and audits had been undertaken and risks identified were in the process of being addressed, however, these were not always completed in a timely manner. For example, a fire audit risk assessment, undertaken on 21 March 2025, had actions to be completed within a 24-hour timescale, however 1 such action was identified as still not completed by the time of our onsite visit. Despite the delay, a risk assessment had not been completed to mitigate how safety would be managed while the service waited for the action to be completed. There was a business continuity plan in place, however there was no evidence to show it was being monitored and reviewed.

The practice did not always make sure there were enough qualified, skilled and experienced staff. For example, the practice had recently appointed a member of staff to be the service’s identified Infection Prevention and Control (IPC) lead, however, they had not ensure that particular member of staff had received the relevant training to undertake the role. 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 people’s individual needs. There were not established and effective systems in place to ensure the safe and appropriate recruitment of staff, in line with national legislation. We found the provider had not conducted appropriate checks for some clinicians prior to their recruitment. For example, a full employment history and relevant references were not in place. Training was not up to date and learning needs and development of staff were not managed appropriately. For example, not all staff had received the appropriate level of safeguarding training applicable to their role; 6 staff were out of date with their Basic Life Support training for adults and children; 3 staff were out of date with Infection Prevention and Control training; 4 staff were out of date with their Information governance training and 3 staff were overdue their Mental Capacity training. Out of the 4 staff personnel files we reviewed, one member of non-clinical staff had not received the appropriate level of children or adult safeguarding, and one clinical member of staff had not received the appropriate level of adult safeguarding training, applicable to their roles.

The practice did not always assess or manage the risk of infection. A recent infection prevention and control audit had been completed in February 2025, however when we asked for previous audits the provider was only able to show us one dated back 2022. There was no evidence of other audits to show the provider had been undertaking regular checks, in relation to IPC, to demonstrate systems and processes were in place and being followed. On review of the service’s cleaning cupboards, it was identified not all cleaning items had appropriate documentation in place to control the substances hazardous to people’s health, in line with national guidance. There was also no evidence of cleaning schedules completed by the external cleaning company to demonstrate that the environment was being cleaned as detailed in the cleaning schedule. We alerted the provider to this and the provider has since provided assurances that this has been put in place. Despite these issues, the service was observed to be clean and tidy, and all handwash dispensers were full and there were appropriate hand hygiene arrangements in place.

The practice did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. From our remote clinical searches, the provider did not have effective systems to manage and respond to safety alerts. For example, historical safety alerts for new patients had not been applied. The provider has since sent us an action plan to ensure this will be completed. The remote clinical searches also identified some patients had not had the required 48-hour steroid inhaler follow up as recommended in line with best practice guidance. The provider sent us an action plan informing us these gaps in monitoring would be addressed immediately. Prescription stationery was not being stored securely and managed in line with national guidance. For example, there was not a clear log of prescription stationary being audited and therefore lacked appropriate security oversight. The service confirmed there was limited oversight of its prescription stationary. On review of the practice’s emergency medicines and equipment no issues were identified. However, the location of the emergency medicines was identified to be a cupboard found on the first floor of the practice. This was accessed via a ‘fob-operated’ door accessible by staff only. We were advised the emergency medicines were kept in this way so patients could not readily access the area. When asked how these would be accessed quickly in the case of emergency, we were told that all reception and administrative staff knew how to do this, however the provider could not demonstrate they had fully assured themselves of this through the completion of scenario-based competency, and had not identified nor mitigated, the risk, should the fob-operated door fail to operate as expected in an emergency situation. Effective systems were in place for checking the expiry dates of medicines. Medical gases were stored safely within the service. Waste medicines were recorded and disposed of appropriately including medicines returned by patients.