Uni-City Medical Centre

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• 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 this key question was rated as Inadequate. We did not assess all quality statements in this key question. We only assessed the parts of the quality statements that were included in the Warning Notices we issued to the provider on 29 July 2025. At this assessment, the service had improved its process in learning from incidents. The monitoring of long-term conditions had been improved and the service now completed recruitment checks in line with national legislation. The rating at this assessment is now Good.

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 service had implemented a new process to review significant events matrix was reviewed and how lessons were now being identified from incident themes. Clinical meetings now include discussions on significant events and related learnings. Staff meetings are planned to incorporate these discussions in the future. The significant events policy has been updated, and complaints were now discussed in both clinical and staff meetings, leading to improvements and greater staff involvement. Staff valued updates about events within the service and benefited from team meetings, which facilitated information-sharing and learning from incidents

The service now 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. There were systems in place for processing information relating to new patient registrations. The service now had a system for processing new patients, and the quantity of summarisation records had significantly reduced however the service still had 8 boxes of summarisation to complete. The service had also implemented a clear process prioritising documents to be reviewed; and at the time of this inspection, there were only 2 documents awaiting review. During our onsite visit we noted the service now had systems and processes to manage people’s test results. Results from our remote clinical searches demonstrated pathology results were being handled promptly. For example, we noted there were 24 pathology results waiting to be processed, with the oldest result being from the 23 October 2025. This was an improvement from the last inspection. Clinical meetings minutes were reviewed as part of this inspection, and these were noted to now be more comprehensive and detailed, with any identified actions being reviewed at the beginning of each meeting.

The service now 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. Safeguarding policies were in place and known to staff, who were now appropriately trained in safeguarding procedures. Since our last inspection, safeguarding training, which was deemed mandatory by the service, was now 100% completed in line with service policy. Improvements had also been made to the systems and processes in place for monitoring people on the safeguarding register, including children at risk. This was reviewed weekly by the safeguarding nurse. The safeguarding list is now proactively managed and addressed in clinical meetings, contributing to coordinated care within a multi-disciplinary framework. Additionally, dedicated safeguarding sessions are held periodically to facilitate comprehensive reviews of complex cases, ensuring timely responses and focused attention to individuals' care and treatment.

The service now detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Staff were now trained in the use of evacuation chairs, and there was now a risk assessment in place. The risk assessment helped minimise risks and ensured the service was prepared to respond effectively during an evacuation, prioritising the safety and wellbeing of everyone on the premises. Staff could recognise a deteriorating patient and knew what action to take. The monitoring of waiting areas had improved with half-hourly checks by reception staff to ensure no person was left unobserved while waiting for their consultation. Posters had also been added around the premises informing people how to get help if needed. Contracts were in place to ensure the premises were maintained. Health and safety risk assessments and audits had been undertaken and any risks identified had been addressed. For example, improvements had been made in relation to the oversight of the risks relating to fire safety, and all actions had now been completed. There was a business continuity plan in place which was monitored and reviewed. Since the last inspection the provider had also created a new procedure for the management of children not brought to appointment. This had resulted in improved oversight of children not being brought to appointments and a quicker referral to safeguarding, if needed.

The service now 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. There were a range of clinical and non-clinical roles within the service. Since the last inspection, the provider had made a significant improvement in staff training. There were now effective monitoring processes to ensure staff completed mandatory training in line with service policy. Improved recruitment checks were in place for the staff records we reviewed, in line with Schedule 3 requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. For example, improvements had been made to the records relating to satisfactory evidence of conduct in previous employment, and staff had relevant employment and professional references in place, in line with service policy. However, we noted there were gaps in employment history of 3 staff records we reviewed. The provider addressed the issue and requested the staff members to fill in missing information during our onsite visit. Staff also told us they were now receiving appropriate supervision and appraisal, which was demonstrated in the records we reviewed.

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. Although the service’s infection prevention and control (IPC) lead had not received additional training to undertake their role, due to the limited availability of such training, the provider had sourced additional external support as an immediate action. This included guidance on how to complete IPC audits and they told us this support had improved and had received external support in the interim to enable them to make progress with their role. IPC audits, known as ‘room audits’ in the service, had been implemented and all staff had had received relevant training. Random spot checks were carried out to verify cleaning completion. The service’s IPC team, comprised of the IPC Lead and Lead nurse, told us there had been a significant improvement since the last inspection, noting an improved learning culture encouraging reflection and this had strengthened the team. The IPC team had also convened small team meetings twice weekly, and these were documented. Risk assessments and audits were completed, and actions taken to mitigate risks. Although the service had implemented some cleaning schedules since our last inspection, there were still gaps in the logging information. For example, records for treatment and consultation rooms were found to be incomplete when reviewed. The provider acknowledged this and referred this back to their cleaning provider to be completed. During our last inspection, clinical waste bins were not locked to the wall to mitigate misuse and ensure safe storage. During our on-site visit, they remained unlocked. The provider was aware of this, and the premise risk assessment acknowledged this still needed to be completed. Despite these issues, we observed the service was clean and tidy, and there were appropriate hand hygiene arrangements in place.

The service now made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened The service had implemented a new process to ensure prescription stationery security was in line with national guidance, this included training 2 staff members to lead on it. During our onsite visit, we noted blank stationery was now being stored securely. However, the process for removing blank stationery for use was not yet fully embedded. For example, boxes had been opened incorrectly and prescriptions were being removed from both the front and back of the pile, rather than sequentially. A full review of this issue was undertaken, which confirmed there were no errors, and the issue was purely related to the order in which the items had been removed. The service was working to improve the process, with one lead and two additional staff trained to support it. The service had reviewed its emergency equipment protocol and relocated the equipment to the ground floor with easy access to the emergency trolley. The staff had also completed some scenario role-play training should an emergency occur on the first floor, and feedback demonstrated this worked well. Staff demonstrated an improved understanding of the requirements for managing patient group directives (PGDs) and were able to provide examples of how these guidelines were now integrated into practice. Ongoing monitoring of the PGDs had been introduced to ensure compliance to promptly address any areas where further improvement was needed. The service had also improved its overall monitoring of Medicines and Healthcare products Regulatory Agency (MHRA) alerts such as implementing discussions of significant alerts to clinical weekly team meetings. The service was able to provide examples of recent MHRA alerts it had recently actioned; for example, a product change from 20-day to 30-day supply of diabetes testing strips.