Musters 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

At our last assessment, we rated this key question as good. At this assessment, the rating remains the same with elements of outstanding. This meant safety was a priority, and people were protected from abuse and avoidable harm.

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 a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

People were supported to raise concerns and staff treated them with compassion and understanding. Representatives from the Patient Participation Group (PPG) felt the service took concerns seriously and proactively made improvements to the service.

The service held clinical and administrative learning event meetings where positive care and near miss events including clinical issues were discussed and learnt from. Information was disseminated to those who were not present at the meeting.

We found that complaints were regularly reviewed to identify trends and that when it was appropriate to do so, learning was shared with staff. Staff felt there was an open culture, and that safety was a top priority. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Learning from incidents and complaints resulted in changes that improved care for others. For example, the practice identified that there had been several negative google reviews relating to gaining an appointment and contacting the practice. During January 2025 the whole practice team met to discuss the reviews, and the practice acknowledged that they needed to make changes. Changes included the implementation of a new telephone system to improve call handing which enable people to select who they needed to talk with and a call back facility to avoid waiting on the phone to speak to someone.

In addition, the practice increased the number of GP appointments, increased the number of face-to-face GP appointments versus telephone appointments and agreed to implement total triage system in April 2025. The total triage system would allow appointment requests to be screened ensuring that people were seen by the right person and within the right timescale to ensure patient-safety.

People were informed of the new total triage system in advance via a newsletter, social media, posters in practice, practice website and a member of the Patient Participation Group (PPG) communicating and explaining the new system to people. The practice also sent a text of apology to all people acknowledging the feedback and that changes had been made to the management of appointments and telephone calls.

Leaders encouraged staff to raise concerns when things went wrong. There was a system in place for staff to report incidents, near misses and safety events the service referred to these incidents as significant events. Significant events that had occurred within the practice were investigated, discussed with staff at team meetings and learning disseminated to improve the service provided. Information was shared to those who were not present at the meeting. The service reviewed all significant events to identify trends and themes and ensured that relevant changes were made to reduce reoccurrence of the events. There was a comprehensive significant event policy in place which was available to all members of staff. We reviewed two significant events and found that a thorough investigation had been completed, and changes had been implemented to avoid issues occurring again that the effectiveness of the changes made was reviewed.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. People felt supported and that clinicians acted in their best interest to keep them safe. The service shared concerns quickly and appropriately.

The service had a clear focus on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They shared concerns quickly and appropriately.

The practice’s safeguarding policy included all aspects of the statutory framework, to include FGM, radicalisation and due regard to the need to prevent people from being drawn into terrorism, modern slavery and human trafficking.

Clinicians we spoke with were aware of safeguarding and specifically talked about how they respond to potential concerns about female genital mutilation (FGM).

Staff were appropriately trained in safeguarding procedures. There was a dedicated safeguarding GP lead and administrator, and the service maintained a list of vulnerable people and acted on concerns working collaboratively with other organisations. Multidisciplinary team meetings were regularly held and used to raise awareness of potentially vulnerable groups of people. Practice GPs, nurse manager, health visitor and school nurse attended the safeguarding meetings. All staff members we spoke with were aware of who the lead safeguarding leading was and how to raise a safeguarding concern.

There were systems in place to follow up people who failed to attend important health care appointments or were frequent attenders to the emergency department, (for example, childhood immunisations or appointments to see a hospital consultant).The GPs provided intelligence for case conference meetings for example in respect of child criminal exploitation and used their wider knowledge of families and communities to inform these meetings.

People were offered chaperones for intimate examinations or procedures, for example, breast examinations. Staff had received training on chaperoning and had a clear understanding of their role.

The service worked with people to understand and manage risks using a holistic approach.

The service provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The practice had engaged with people to obtain their views on access to a health care professional.

Results showed that people were satisfied with access. National GP Patient Survey data and feedback received from people reflected that 78.8% of people responded positively to the overall experience of contact with their GP practice with the national average being 73.9%. This is higher than the national average satisfaction percentage.

There were systems and processes in place to identify and manage emerging risks of people and regular liaison with other health care professionals to highlight the risk, e.g. with the community nursing team, palliative care team and referral to hospital consultants.

Systems were in place for checking and monitoring emergency equipment and medicines. The practice kept recommended emergency medicines and equipment, including oxygen, and defibrillator at both the main and branch site. All staff had been trained in basic life support. Staff could recognise a deteriorating person and knew the action to take. People were advised on risks related to their condition and the actions to take if their condition deteriorated.

The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The practice was responsible for all risk assessments, cleaning arrangements and maintenance of the buildings. The practice had clear security arrangements to keep people and staff safe and access to non-public areas were adequately restricted and monitored.

We saw that the practice had effective systems to monitor and comply with mandatory risk assessments, including fire safety and legionella testing to ensure that people and staff remained safe.

Records showed fire alarms were routinely tested, and the practice had appointed fire marshals to direct patients and staff in the event of a fire. Staff completed fire training and attended regular fire drills which included the evacuation of the public.

Electrical equipment had been calibrated and tested. Safety alerts relating to equipment were shared with the relevant staff and acted on.

We observed that the practice was accessible for all people and included space for wheelchairs and prams. Hallways and corridors were clean and tidy and free from clutter. Staff offices were secure, and access restricted by electronic key-fobs.

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.

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.

Staff received appropriate training and told us they were supported to develop and progress within the team. The service had access to additional staff employed through their primary care network (PCN). Processes had been established to ensure staff working for but not directly employed by the practice were recruited safely, had received appropriate and up to date training and were working within their agreed areas of competence. For example, a sessional GP, physiotherapist, pharmacist and social prescriber.

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

There were systems in place to assess and manage the risk of infection. We saw evidence that clinical rooms were checked daily for cleanliness and equipment was cleaned after each use. Daily room checks and cleaning tasks were recorded electronically at the end of each clinical session and retained for auditing purposes. For example, blood pressure cuffs were wiped with antibacterial wipes before being used on another person and cleaning of surfaces after each person.

Disposable curtains were available is all clinical rooms which were recorded with a diary date for when they needed to be changed. Medical couches were all in good state of repair and were visibly clean with disposable couch rolls for use between each person. Records showed that coaches were cleaned after each use to manage the risk of infection.

The service used disposal single use equipment at all times and records showed that equipment was appropriately disposed of after use. For example, cervical cytology speculums, and mouth pieces for the management of respiratory conditions, such as spirometry breathing measurements.

Infection, Prevention and Control (IPC) audits had been completed. There was a designated (IPC) nurse lead who had a good oversight of IPC. The practice manager had an excellent oversight of IPC responsibilities. Staff were aware of who the IPC lead was. Staff had received relevant training in IPC. Risk assessments and audits were completed, and action plans were in place to mitigate potential risks. For example, a recent IPC audit identified limescale on taps which posed an infection risk. This was immediately rectified and recorded within the audit.

Clinical waste procedures were in place. Staff had a complete record of staff eligible for immunisations, in line with national guidance. People told us that they thought the practice was clean and tidy.

Cleaning cupboards were visibly clean and single use equipment was used. For example, disposable colour coded mop heads and cloths. Cleaning of all rooms within the building was electronically recorded and retained for audit purposes. A regular cleaning audit was completed by the practice manager.

The service 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.

Clinicians involved people in reviews of their medicines and helped them understand how to manage their medicines safely. People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms from their medicines. Staff followed protocols to ensure they prescribed all medicines safely, and ensured people received recommended medicine reviews and monitoring. Protocols effectively supported the safe prescribing of medicines and staff involved people in reviews of their medicines.

Medicines were prescribed appropriately to optimise care outcomes, including antibiotics. Prescribing data reviewed as part of our assessment confirmed this. For example, data on antibiotics prescribing for the treatment of uncomplicated urinary tract infections showed the practice performance was within national averages relating to safe prescribing, and they had consistently done so since 2020.

Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring. For example, prescribing of pregabalin or gabapentin which is medicine used for the management of pain in long term conditions was below the national averages. The service limited the prescribing of these medicines to one month at a time and regular medication reviews were completed to monitor compliance and check ongoing suitability of the prescribing. One of the salaried doctors who worked at the practice monitored the prescribing of these medicines and controlled drugs to check that people were not ordering their medication too early, or over ordering medication.

Prescribing of hypnotic medicines used for treating severe insomnia and interferes with normal daily life were below national averages.

We did not identify any concerns as part of our review of medicines. We reviewed clinical records as part of our assessment of Musters Medical Practice. A sample of records reviewed of five people with chronic kidney disease found that people were being appropriately monitored, and blood samples had been taken to monitor kidney function. We also reviewed a sample of records for people who were prescribed medicines for hypothyroidism, (underactive thyroid) who had not had a review of their condition within the previous nine months. We found there was an effective system in place for inviting people for reviews and following up non-attenders regularly, including those who were receiving treatment outside the NHS.

Recall processes were robust and demonstrated that people’s safety was a priority. The practice utilised varied methods of communication tools to contact people, including, text messaging, phone calls, letters and telephone calls. Where people’s first language was not English, they received invitations in their own language.

Systems were in place to manage and respond to Medicines and Healthcare Products Regulatory Agency (MHRA) alerts and medicine recalls. Systems for managing the prescribing of medicines and treatment of other medicines were safe and met people’s needs.

Systems were in place for checking the stock levels and expiry dates of all medicines, including emergency medicines and vaccines. Medical gases, such as oxygen, were stored securely and safely and they had completed required safety risk assessments. Prescription stationery was stored securely and tracked throughout the practice utilising a robust process which all staff were aware of. Prescriptions in printer drawers were stored securely overnight.

Waste medicines were disposed of appropriately including medicines returned by patients.