Abbey Meads Medical Group

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 service since its registration with CQC. This key question has been rated as Good.

This service scored 78 (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.

Managers encouraged staff to report concerns and discuss incidents when things went wrong. Staff meetings were used to review clinical issues, share learning and agree actions to improve people’s safety. Safety events were anonymised and shared through Primary Care Network (PCN) meetings to promote shared learning and help prevent recurrence. Minutes of these meetings were made available to staff who were unable to attend. Staff described an open culture in which safety was prioritised and gave examples of incidents and near misses being investigated and resolved. For example, following a recent telephone system outage, the service reviewed its business continuity plan and introduced a process whereby each day’s appointment lists were printed in advance. This helped ensure staff could maintain continuity of care and contact people with booked appointments if electronic systems or telephone access were disrupted.

The service had systems for recording and investigating complaints. When things went wrong, staff apologised and supported people in line with the duty of candour. Learning from incidents and complaints led to changes that improved care for others. For example, the service improved communication with people about what should be requested as a repeat prescription and when a clinical review or appointment may be needed instead. This helped people understand the appropriate route for medicine requests, reduced the risk of inappropriate repeat prescribing, and supported safer management of medicines.

The service recorded significant events, although the number reported appeared low. Leaders had identified this and discussed at senior management meetings. Staff had also been reminded to report incidents to support learning and continuous improvement. Leaders monitored significant event reporting and reminded staff through team meetings and internal communications when and how to record incidents and near misses. This reinforced staff responsibilities, encouraged earlier reporting of lower-level concerns and supported a more open culture of learning.

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

The service had systems to process new people information and summarise records promptly. At the time of inspection, there were no records awaiting summarisation, and all records, including paper records, were summarised on the day they were received. Monthly spot-check audits monitored the timeliness and accuracy of this process. This meant clinicians had immediate access to up-to-date information at registration, supporting safe care, reducing the risk of errors, and enabling prescriptions to be issued promptly. The service also used the NHS England GP2GP system to transfer medical records electronically and securely when people changed GP practice, supporting continuity and safety of care.

Clinical system review showed referrals, test results, tasks, coding and correspondence were managed in a timely way. The service used Anima, an NHS-approved artificial intelligence tool, to support document processing, record summarisation and the identification of appropriate clinical codes. Administrators retained oversight and followed a standard operating procedure. Monthly audits reviewed workflow, summarisation and coding accuracy, with errors addressed and learning shared across the team. The service also monitored document processing alongside staffing levels and other factors that could contribute to delays, helping ensure clinicians had timely access to current information.

The impact for people was that clinicians had accurate, up-to-date information available at the point of care, supporting safer prescribing, timely follow-up and continuity of care. Same-day summarisation, prompt review of results and correspondence, oversight of urgent referrals and coordinated multidisciplinary working helped reduce delays, identify risks earlier and ensure people received safe, joined-up care. The service had systems to share information with staff and partner agencies to support safe care and treatment. It monitored referral delays and maintained clear oversight of urgent suspected cancer referrals, previously known as the two-week-wait pathway. A tracking spreadsheet tracked was audited to confirm people had been booked with secondary care providers within the expected 28-day timeframe.

The service worked effectively with other providers to support shared care and safe transitions between services. It was linked with services across the PCN and collaborated with secondary care, community teams and local partners through agreed referral pathways, shared care arrangements and multidisciplinary meetings. Discharge summaries and specialist correspondence were reviewed promptly, with follow-up actions and medicines monitoring completed where required to support safe ongoing care. People with complex needs benefited from coordinated care planning, regular multidisciplinary meetings and information sharing with community teams, hospice services and other healthcare partners. This helped ensure risks were identified, actions were agreed and care remained coordinated across services.

The service had systems in place to protect confidential information and support safe information sharing. Staff completed information governance training, followed clear processes for managing records and subject access requests, and understood their responsibilities for maintaining confidentiality. The service reviewed and learned from a potential data breach, identified further improvements to strengthen information governance arrangements and reduce future risks.

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.

Safeguarding policies were in place, and staff were aware of how to access and follow them. Staff had received appropriate safeguarding training. The service maintained systems to identify people at risk and acted on safeguarding concerns in partnership with relevant organisations.

Where people had more complex health needs or safeguarding risks, staff worked with different teams involved in their care to identify and manage risk. Information was shared between community teams, hospice services and other healthcare partners. This helped ensure risks were identified, actions were agreed, and care was coordinated.

Staff with designated safeguarding responsibilities, supported by administrative staff, maintained oversight of safeguarding concerns and activity. The service used safeguarding audits to review. its arrangements and identify areas for improvement.

Systems identified and monitored children and adults subject to safeguarding arrangements, with concerns clearly flagged in people’s records. For example, staff reviewed monthly safeguarding information received from the local authority, coded children’s records to identify safeguarding concerns and reviewed child protection conference minutes. This helped ensure clinicians remained aware of current risks and agreed plans. Staff joined quarterly multi agency safeguarding meetings, strategy discussions and child protection conferences. These arrangements supported timely information sharing and coordinated action to help protect people from harm.

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.

In the 2026 National GP Patient Survey, 85% of respondents said they were involved as much as they wanted to be in decisions about their care and treatment.

People received advice about risks associated with their condition and what action to take if their symptoms worsened. This included safety-netting advice during consultations and reviews, with people signposted to urgent or emergency services where appropriate. For example, people with long-term conditions were given safety-netting advice during reviews, including when to seek urgent help if symptoms worsened.

The service detected and controlled potential risks in the care environment. They had systems in place to ensure equipment, facilities and technology supported the delivery of safe care. Health and safety checks were completed across the premises, including treatment and consultation rooms, emergency equipment and vaccine fridges. Checks included clinical and external areas. Equipment was monitored to make sure it was available, safe to use and stored correctly. For example, vaccine fridge temperatures were checked to make sure vaccines remained safe and suitable for use.

Environmental risks were identified and managed, contracts were in place to maintain the premises, and health and safety audits and risk assessments were completed with action taken where needed. A business continuity plan was also in place and was monitored and reviewed.

Portable appliance testing and equipment calibration had been completed and were routinely monitored. Risks relating to fire, hot water systems and legionella had been assessed and managed. A fire evacuation plan and policy were in place, and relevant staff had completed fire warden training. Staff had completed evacuation chair training, and a related risk assessment was in place. Scheduled safety checks were completed on the fire alarm system, emergency lighting and equipment.

During the onsite visit, first-floor windows were open widely due to the warm weather. The service reviewed the associated risks and installed window restrictors to help maintain people’s safety.

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 service employed a range of clinical and non-clinical staff. Training was relevant, up to date and monitored through an effective oversight process, including monthly compliance audits and reminders for overdue training. Staff had equal access to learning and development opportunities, and the service supported internal progression, which helped retain experienced staff. Staff said they were supported and valued, could broaden their skills by working across different areas of the service, and had access to external training to strengthen their knowledge and improve outcomes for people.

Staff worked within agreed areas of competence, which were assessed and recorded through annual appraisals and clinical supervision with team leads. They received role-specific inductions, including shadowing opportunities and meetings with leaders.

Records showed regular clinical supervision for non-medical prescribers, in line with the service’s clinical supervision policy. Informal support was also available through case discussions, group reflection and lunch-and-learn sessions.

Safe recruitment processes were followed. Recruitment and human resources records were in line with service policy and Schedule 3 of the Health and Social Care Act 2008. We reviewed 4 staff records and identified some gaps in references and application forms for staff who had transferred from a previous service under Transfer of Undertakings (Protection of Employment) Regulations 2006 (TUPE) arrangements. The service had completed risk assessments to address these gaps and set out how these would be monitored. Appropriate recruitment checks had been completed and records were maintained accurately.

Staff said staffing levels were sufficient to manage workloads and avoid task backlogs. Rotas were planned with oversight to ensure appropriate cover. If a clinician was absent at short notice, booked appointments could be moved to protected same-day slots so people could still be seen.

Where improvements were identified, action was taken and learning was shared with the wider clinical team. Regular documented supervision, case discussions and reflective learning supported safe prescribing and ongoing professional development.

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. There was a designated infection prevention and control lead, relevant staff training, and systems to audit, monitor and manage infection prevention arrangements.

The service had a clear infection prevention and control (IPC) policy that referred to relevant national guidance, including the Health and Social Care Act 2008 Code of Practice. The policy set out staff responsibilities and included an audit schedule covering areas such as hand hygiene, sharps safety, aseptic technique and other IPC practices. Records showed audits were completed as planned, with actions taken to address any issues identified. IPC risks were assessed, monitored and mitigated, with actions taken to reduce risk of infection to people, staff and visitors.

Spillage kits were available, and staff had been trained to handle specimens safely. Cleaning cupboards were checked, and suitable processes were in place to manage substances hazardous to health. Clinical waste was managed through clear processes, with waste correctly segregated and disposed of safely in line with current infection control standards.

Evidence reviewed showed that IPC audits had been completed regularly, with findings used to drive improvement and strengthen infection prevention practices. Cleaning arrangements had been monitored through room checks and cleaning records, and clinical areas were expected to be cleaned daily. Hand hygiene audits had also been undertaken, and staff had received feedback and learning where improvements were identified. For example, evidence showed that hand hygiene spot checks had been introduced and tracked, and cleaning and maintenance checks for clinical equipment and storage facilities had formed part of routine monitoring. Internal cleaning schedules were in place for clinicians, but completed records from the external cleaning contractor were unavailable. The service responded promptly by strengthening oversight arrangements and introducing a contractor cleaning record to provide additional assurance that cleaning activities were completed as expected. During the onsite visit, the environment was visibly clean, with handwashing supplies, aprons and gloves available.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They always involved people in planning, including when changes happened.

Remote clinical searches showed medicines and treatments were managed safely and reflected people’s needs, preferences and circumstances. The pharmacy team oversaw review dates, prescribing alerts, clinical searches and monitoring for higher-risk medicines. Following audit findings, the service introduced a standardised approach to strengthen oversight and support identification and management of people at higher risk. Clinical searches were also used to respond to medicines safety alerts, monitor long-term conditions and prioritise reviews for people taking multiple medicines or requiring additional monitoring. The pharmacy team reviewed prescribing risks in regular meetings and shared learning with staff.

Staff involved people in reviews of their medicines and supported them to understand how to manage medicines safely. People were told what to do and who to contact if their condition did not improve or if they experienced unexpected symptoms. Staff received regular training and had their competency in medicines optimisation assessed. They felt confident managing the storage, administration and recording of medicines. Prescription stationery was managed securely. Staff followed protocols to prescribe medicines safely and ensured people received recommended reviews and monitoring. Medicines, including those requiring additional controls, were stored securely and at appropriate temperatures. Staff regularly checked stock levels and expiry dates, including emergency medicines and vaccines. Waste medicines, including those returned by people, were recorded and disposed of appropriately. Medical gases were stored safely and appropriate risk assessments had been completed.

The provider had effective systems to manage and respond to medicine safety alerts and medicine recalls. Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring. Suitable processes were in place for dispensing medicines where relevant. Prescribing data reviewed as part of the assessment supported this. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.

The service supported non-medical prescribers through regular clinical supervision, competency reviews, case discussions and reflective learning. Staff received ongoing support to maintain and develop their prescribing skills, and supervision records demonstrated oversight of prescribing practice. Audit findings were used to identify learning opportunities and support continuous professional development.