Sarephed Medical 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

This is the first inspection for this service since its registration with CQC. This key question has been rated as Good.

We looked for evidence that people were protected from abuse and avoidable harm.

We found that systems were in place to keep people safe. The provider had a safeguarding procedure in place and staff we spoke with knew how to raise a safeguarding concern and who the safeguarding lead person was.

Health and safety procedures were in place and monitored. Risk assessments were being carried out. While the premises were maintained to ensure people’s safety, we found that fire extinguishers had not been checked since May 2024. The provider supplied evidence after the site visit to show that they had now been checked by a professional fire service who they had set up a contract with.

We found where incidents had taken place appropriate processes were in place to investigate incidents and to share learning with the staff team.

This service scored 72 (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 felt supported to raise concerns and felt staff treated them with compassion and understanding. Staff used team meetings to raise and explore concerns, which promoted shared learning and contributed to ongoing service improvement. Staff told us they worked within an environment of openness and felt they could approach managers whenever they needed to. The provider had a complaints process so people could raise concerns, and we saw that these were acted on. For example, the telephone recall system was set up because of a complaint. The culture within the practice was friendly and open. Staff told us they enjoyed coming to work.

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.

The processes the provider had in place ensured partners like The Linkway Medical Practice worked closely together. When the provider had limited resources to meet peoples care and treatment needs. People were referred to The Linkway to ensure they received care. For example, if there was limited nursing staff, then nursing care could be delivered from The Linkway.

There were systems in place for processing information relating to new patients. The service worked with partners to deliver shared care and when patients moved between services. Referrals and test results were managed in a timely way, and we found that the provider’s systems for managing information worked to ensure people’s critical care information was up to date and accurate.

The provider was part of a Primary Care Network (PCN) and had regular communications and regular meetings with all partners within the network to ensure people’s care and treatment was delivered in a timely manner.

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.

We found safeguarding policies were in place and staff knew how to raise safeguarding concerns. Staff told us they had received the appropriate training to the level of their job. The provider knew who were vulnerable so they could act on concerns in partnership with other partners to keep people safe 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.

Emergency equipment was available and maintained. Staff could recognise a deteriorating patient and knew of action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

Staff were all trained had received mandatory training like basic life support to ensure they had the skills to support people appropriately.

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.

These contracts were monitored and maintained to ensure people’s care and treatment was delivered in an environment that was safe. The majority of equipment was checked regularly; however, the fire extinguishers we found had not been checked since May 2024.

Health and safety risk assessments and audits had been undertaken and risks identified had been addressed. There was a business continuity plan in place which was monitored and reviewed as appropriate.

While the service did make sure there were enough qualified, skilled and experienced staff. We found not all staff received regular supervision. Clinical staff told us they received regular supervision from GP’s; however, we found no evidence that non-clinical staff were receiving the same. The provider told us this would be implemented immediately. Staff attended regular staff meetings and received annual appraisals.

The provider had a process in place for the recruitment of appropriate staff. As part of their recruitment process references, Disclosure and Barring Service checks (DBS) and an induction process was in place to ensure the appropriate staff were employed.

The provider ensured clinical staff had the appropriate qualifications to deliver clinical care and their certifications were up to date.

There were a range of clinical and non-clinical roles within the practice. We found training was available and up to date, learning needs and development of staff was managed appropriately and monitored, and staff were working within their agreed areas of competence.

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.

The provider had procedures in place to manage infection control and staff told us they received the appropriate training. We found there was a designated infection control lead in place to support staff when needed.

Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks.

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.

A random selection of clinical searches was carried out to check on how people’s medicines were being managed and monitored. We looked at a random sample of 5 people’s clinical records who had long term conditions like asthma and who had received 2 or more courses of rescue steroids in the last 12 months. We found their care and treatment was being managed appropriately with no concerns identified.

We looked at clinical records for 5 people who had been prescribed ACE inhibitors and Angiotensin II receptor blocker (ARBs) medicines used to control blood pressure. We found all people were being managed as required and were followed up as required when they failed to attend for reviews.

We checked the clinical records for 3 people who should have had medicines reviews carried out and found they had all been completed.

The provider had effective processes in place to manage medicines and device safety alerts. Records showed these were reviewed in a timely manner, with appropriate actions identified and completed where required. Staff told us they discussed relevant alerts during regular meetings and had access to up‑to‑date information to support safe practice.

Staff received regular training and were competency assessed in medicines optimisation. They told us they felt confident managing the storage, administration and recording of medicines. Established prescribing protocols were followed to ensure medicines were prescribed safely, and people received recommended medicines reviews and appropriate monitoring.

Staff regularly checked medicines stock levels and expiry dates, including emergency medicines and vaccines. Waste medicines were recorded and disposed of appropriately, including those returned by patients. Medical gases, such as oxygen, were stored safely and the required safety risk assessments were in place.

Staff followed established processes to ensure people prescribed medicines with specific risks received the recommended monitoring. Prescribing data reviewed during the assessment showed the provider prescribed responsibly to optimise care outcomes, including antibiotics. For example, the number of antimicrobials prescribed was lower than local and national averages.

The provider had a programme of regular clinical audits focused on improving the safety and effectiveness of prescribing. We found a small number of paper prescriptions were not stored as required; this was addressed and resolved before the site visit was completed. The provider used the Electronic Prescription Service (EPS), which reduced the need to issue paper prescriptions.