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

We found during our assessment that the service had a proactive and positive culture of safety, based on openness, and ongoing learning. To support this approach the provider had developed and implemented policies and processes for complaints, significant events, and quality improvement. These documents were available to staff on the practice’s shared information access platform.

Staff we spoke with during interviews, and who gave us feedback via questionnaire, told us that they knew how to report incidents. In addition, they felt confident that incidents that they reported would be investigated, and that learning would be used to improve the service. For example, the provider had identified incidents whereby 2-week wait cancer referrals had not been progressed. These incidents had been fully investigated, and actions taken to prevent recurrence such as the use of a mandatory pop-up prompt to ensure staff followed the required process, and by undertaking awareness raising amongst staff of the issue. Staff told us that the provider operated a blame-free culture which supported the open and honest reporting of incidents.

Over the previous 12 months the provider had recorded 18 incidents and events, and received 21 complaints for both Wetherby Health Centre and Bramham Medical Centre. Governance and oversight in relation to learning events such as incidents and complaints were in place, and were discussed at both senior management meetings and team meetings.

The service 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.

We saw that there were systems in place for processing information relating to new patients, in addition to this, new patients were offered new patient registration health questionnaires, and new patient consultations to help inform the practice of their needs. Information from the provider and checks on records and incoming correspondence and test results, showed that these were handled and processed in a timely way.

The provider had clear referral processes in place, and members of staff we spoke with fully understood the referrals process. Monitoring systems were in place to track urgent referrals such as those related to cancer 2-week waits.

The provider’s clinical records system allowed the sharing of information with other health and care providers including out of hours services, community services, and safeguarding teams.

The service worked with patients and health and social care partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving patient’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

We found that staff had a good understanding of safeguarding. They gave good examples of when they would raise concerns, and knew the appropriate routes to take to inform appointed internal safeguarding leads and external partners. The provider had developed and adopted a safeguarding policy which had last been updated in October 2025. There was also a trans inclusion policy which included associated safeguarding risks.

We saw that the practice utilised their clinical system to support their safeguarding approach. For example, they recorded if a child was not brought in for an appointment, and used this to track any developing concerns. Data from clinical records was used to update the safeguarding risk register.

Safeguarding concerns could be raised and discussed in a number of fora which ensured staff were aware of current and emerging issues. This included at daily meetings (huddles), monthly internal meetings, and formal discussions with multi-disciplinary partners.

Checks on training records showed that staff had been trained in safeguarding to levels appropriate to their roles.

Staff at the practice worked with patients to understand and manage risks. We saw that staff provided care to meet patient needs that was safe, and supportive.

Results from the 2025 National GP Patient Survey showed that 92% of patients reported that they were involved as much as they wanted to be in decisions about their care and treatment during their last appointment, compared to local and national averages of 91%.

We found during our visit that emergency equipment was available, and that this equipment was suitable for use, and had been regularly maintained. The provider had systems in place for the checking of emergency equipment and medicines, and we saw that this had been undertaken.

Staff records showed that mandatory basic life support training covering both adults and children had been undertaken. Staff told us during interviews that they were aware of how to raise concerns regarding emergency situations.. The provider had developed a protocol to assist non-clinical staff to identify patients who showed signs of deterioration, or needed immediate support.

The service worked to identify and control potential risks within the care environment. The service ensured that equipment and facilities supported the delivery of care and kept both patients and staff safe. The practice had put policies and processes in place which gave assurance that health, safety, and wellbeing requirements were met. For example, we saw that legionella and fire risk assessments had been undertaken.

We saw evidence that regular testing, maintenance, servicing, and calibration of clinical equipment had taken place. We found that fire safety risks were being managed, and that regular fire alarm checks and fire evacuation drills had been carried out.

To support the maintenance of a safe environment for both patients and staff the provider undertook health and safety audits at both sites. Results from the latest audits undertaken showed high overall compliance.

There was a business continuity plan in place which was monitored and reviewed.

The practice made sure there were always enough qualified, skilled, and experienced staff, who received thorough support, supervision, and development opportunities. They worked together to provide safe care that met individual needs.

Since taking over the contract for Wetherby Health Centre, in addition to their existing practice at Bramham Medical Centre in July 2023, the provider had prioritised the recruitment of a new clinical and non-clinical team to support their patients. Within 12-18 months we saw that the provider had successfully built a fully substantive operational team able to meet the needs of their patient population at both sites.

We saw that induction and support procedures were in place for new staff. Induction included an introduction to the practice, mandatory and role specific training, and ongoing mentoring, supervision and appraisal.

We saw that the provider had a good understanding of patient demand and patient flows. They used this past patient demand data to inform their access and appointment processes, and to ensure that there were enough qualified, skilled, and experienced staff on duty. Rotas were in place to support this activity. When we spoke with staff, they told us that they felt that there were appropriate numbers of staff on duty. For example, at peak periods additional staff could be allocated to answer telephones to reduce waiting times, and to reduce staff pressure. An understanding of demands and capacity had driven decisions by the provider to increase staffing numbers, including the decision to recruit an additional GP.

Checks on personnel records showed that staff had regular appraisals, one-to-ones, and access to mentorship and other support when required. This was confirmed by staff that we spoke with or received questionnaires from during the assessment. In respect to assessing staff competence, we saw that clinical and non-clinical supervision was embedded within the practice. Comments from staff made it clear that they felt they were able to approach others for advice whenever they felt this was required. The provider operated with a shift leader/duty doctor available to deal with routine tasks and emerging issues or requirements, this included the support of other staff.

Clinical and non-clinical audit and assessment supported the supervision of staff. For example, we saw evidence of the oversight of prescribing practice.

The provider had developed several protocols and assistive tools for staff which supported the delivery of their duties. These included a care navigation policy, and a toolkit to support telephone triage.

The service had measures in place to manage infection prevention and control (IPC). This included the appointment of a trained staff member to act as the practice’s IPC lead, the development of an IPC policy which was kept regularly updated, and IPC audits which assessed the levels of operational compliance against standards. Audits included full IPC audits and regular hand hygiene audits. Additional protocols were in place which supported good IPC practice, this included procedures for aseptic techniques and managing sharps injuries. The overall management of IPC processes and controls under the IPC lead was very organised and thorough.

Staff undertook IPC training during their induction, and annually thereafter. We saw that as part of the recruitment process the provider had assurance that staff had received the necessary immunisations and vaccinations to undertake their roles safely.

Our onsite visit to the practice found it to be clean and in a good overall structural condition. We found that clinical waste was being handled and stored safely, and that a clinical waste disposal contract was in place.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. This involved assessing patients current and ongoing needs. Staff received regular training, and felt confident managing the storage, administration and recording of medicines. The provider managed prescription stationery appropriately and securely.

Work procedures and clinical templates were in place which ensured medicines were prescribed safely, and our remote clinical searches showed that patients received recommended medicines reviews and monitoring. For example, all patients prescribed Disease-Modifying Anti-Rheumatic Drug (an immunosuppressant, which helps reduce inflammation, and is used to treat conditions such as rheumatoid arthritis) had received the required monitoring. In addition, only 4 patients (0.4% of those prescribed) in receipt of ACE inhibitors or Angiotensin II receptor blockers (used to treat high blood pressure and heart failure) were outside the required monitoring period. Of these patients 3 had been contacted for monitoring and review and the other patient was out of the country for a period of time and would be recalled on their return.

Over the previous 3 months, we saw that 1,031 medication reviews had been undertaken by the provider in conjunction with staff from their primary care network. We saw that assessments we reviewed were timely, comprehensive, and carried the appropriate level of detail.

Other prescribing data we reviewed as part of our assessment confirmed that medicines were managed effectively. For example, the number of antimicrobials and psychotropic medicines (used to support and treat patients suffering from mental ill health) issued by the provider was either lower than, or in line with, national averages. Effective prescribing practice was supported by a programme of regular clinical audits of prescribing that focused on improving care and treatment, and assessing compliance with guidance and best practice.

The provider worked with patients to reduce opioid dependence (a broad range of medicines used to treat pain whose continued use can lead to dependence). Patients had been allocated a named GP to promote continuity and build trust, and were offered frequent weekly or monthly appointments to review their symptoms, medicines usage, and necessary withdrawal support. Prescribing was moved from longer repeat quantities to shorter and more controlled intervals. Other actions included scheduled weekly prescription releases and the referral of patients to a local substance-misuse support service.

Staff regularly checked the stock levels and expiry dates for medicines stored within the practice, this included emergency medicines, and vaccines. Medical gases, such as oxygen, were stored safely, and required signage and completed safety records were in place.

The provider had effective systems in place to manage and respond to safety alerts and medicine recalls. Alerts and recalls were discussed and shared with staff in a variety of ways. These included at daily staff meetings (huddles), at regular team meetings, and via emails.