LADMS GP Enhanced Access Service - Alford Memorial Hall

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 had not inspected this service before. At this assessment we rated this key question as requires improvement. This meant safety was not always a priority, and people were not always protected from abuse and avoidable harm.

This service scored 56 (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 always demonstrate a positive approach to safety and learning. Managers told us they listened to concerns and took steps to investigate safety events. However, we found little evidence that learning regarding complaints and significant events was shared with staff. Whilst we were told there were regular staff meetings, we only saw three sets of minutes for the twelve months prior to the assessment. Staff we spoke with told us that they had not received any information regarding outcomes of complaints, significant events or incidents.

The service had systems in place to manage complaints and processes for reporting incidents, near misses and safety events when they arose. The service provided four complaints and significant events records for the inspector to review. We saw complaints were investigated and learning had been identified. For example, the service received a complaint pertaining to availability of equipment within the enhanced access service. As a result, the service initiated regular site inspections to check equipment.

However, we did not see evidence of further dissemination of learning to the wider team of complaints or significant events.

The service did not have systems in place to support the delivery of safe care.

We found that leaders did not have oversight of safe premises, infection prevention and control, and emergency equipment at the locations we assessed. For example, the service was unable to assure us that emergency equipment was regularly checked to ensure that equipment was working and emergency drugs were in date.

The service worked with people and other healthcare providers to support continuity of care. People received follow-up appointments where appropriate, including review of test results and advice where needed. Referrals, correspondence and test results were managed in a timely way.

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 to relevant organisations quickly and appropriately to keep people safe.

The practice’s safeguarding policy included all aspects of the statutory framework, to include female genital mutilation (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.

Staff were appropriately trained in safeguarding procedures and acted on concerns working collaboratively with other organisations.

People were offered chaperones for intimate examinations or procedures, for example, breast assessments. 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 receptionists at the enhanced access unit had a daily checklist to complete to include the opening and closing of the unit.

The service had engaged with people to obtain their views on access to a health care professional via comment cards available at all locations. We saw feedback and compliments from six people who had used the service which were all positive.

The service 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.

Managers were unable to assure us that they had oversight and maintenance of emergency medicines and equipment at the Alford site. Adequate systems were not in place for checking and monitoring emergency equipment and medicines. We found that dispersible aspirin used to symptoms of a heart attack was missing from the emergency medicines. The Resuscitation Council UK recommends that staff should have immediate access to all resuscitation equipment and medicines. When we examined the emergency medicines staff did not know where the dispersible aspirin was located. We were later informed that aspirin was available in the doctor’s bag.

People were greeted on arrival by a dedicated receptionist. The building was not a purpose-built surgery, and facilities were shared with other community groups during the week. The service had adequate toilet facilities. The waiting room was cluttered with unused chairs and tables. Although the site looked clean the service was unable to produce evidence that regular cleaning and decontamination checks were completed. Managers failed to provide assurance that mandatory risk assessments had been completed to include mandatory fire safety checks, fire risk assessment, and legionella risk assessments. Therefore, we were not assured that people were being kept safe.

Ramps were available for people to access the building, and there was access for wheelchairs and prams. Consulting rooms were on one level. Hallways and corridors were clean and tidy and free from clutter. The waiting room could not be monitored by the reception due to the building layout and therefore, the service could not assure that staff and people were safe.

The service did not make sure that there were enough qualified, skilled and experienced staff. The service was unable to evidence that staff were registered with mandatory professional organisations, received regular and support, supervision and development to provide safe care that met people’s individual needs.

We were not assured that the service has safe and effective staffing procedures and checks in place to ensure that people were kept safe. The service mainly employed clinical staff on a temporary basis via locum agencies. Across the 5 enhanced access locations, LADMS utilised the services of 10 receptionists, 4 advanced nurse practitioners and 21 doctors, either via locum agencies, or direct employment with LADMS. Additional administrative staff and management were employed by the provider organisation, including executive chairperson, chief operating officer, and wider office management and administrative team members to support the delivery of the enhanced access service.

We generally found mandatory training was up to date, however information governance compliance was 71% and mental capacity compliance was 59%. The service maintained a dashboard to record locum and employed doctor and nurse practitioner mandatory training and mandatory registration compliance. The dashboard showed that one staff member only had 53.6% mandatory training compliance. In addition, the dashboard indicated that medical indemnity insurance, registration with the General Medical Council (GMC) or nursing and Midwifery Council registration (NMC) had not been recorded or had not been updated by the organisation. The service was unable to assure us that 2 GPs had valid medical indemnity insurance, nor that 4 GPs had valid and in-date registration with the GMC which was noted as expired or overdue. Clinical appraisals were not recorded for all staff members. We looked at 5 staff files; we found references were absent in 2 files. We also found that 2 GPs did not have a curriculum vitae (CV) on file.

We reviewed the clinical oversight of the doctors and nurse practitioners who worked with the service. We saw evidence that monthly audits were being completed to review the appropriateness of medications prescribed and record keeping. However, due to staff turnover and staff sickness clinical oversight reviews had not been completed since October 2025. Failure to complete regular clinical oversight was acknowledged within meeting minutes dated 7 April 2026, where leaders commented that they needed to undertake peer reviews and complete medication audits to provide quality improvement evidence in readiness for the announced CQC assessment.

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of infection spreading or share concerns with appropriate agencies promptly. The service ensured staff received immunisations appropriate for their role, in line with national guidance.

Infection, Prevention and Control (IPC) audits had been completed; however, all audits were completed after we had announced our planned onsite assessment. The service was unable to provide any previous audits. Staff had received relevant training.

The receptionist completed a daily room check upon opening and closing the enhanced access location. We did not see any evidence that clinical rooms were checked for cleanliness or that equipment was cleaned after each use. We did not see any evidence of cleaning audits, despite asking leaders for these audits.

Disposable curtains were available in all clinical rooms which were recorded with a diary date for when they needed to be changed. Examination couches were all in good state of repair and were visibly clean with disposable paper covers for use between each person.

The service used disposal single use equipment, for example, cervical cytology speculums. Clinical waste procedures were in place.

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. People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms from their medicines.

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 were safe and met people’s needs.

Medicines were prescribed appropriately to optimise care outcomes, including antibiotics. Prescribing data reviewed as part of our assessment confirmed this. For example, data on antibiotic prescribing for the treatment of uncomplicated urinary tract infections showed the service’s performance was within national averages relating to safe prescribing.