St Georges 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

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 Requires Improvement.

The service was in breach of legal regulation in relation to Safe Care and Treatment.

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 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. Managers encouraged staff to raise concerns when things went wrong.

During staff meetings, the whole team discussed and learnt from clinical issues. Staff reported that minutes of meetings were not always shared with staff that could not attend the meeting in person.

Staff felt there was an open culture, and that safety was a top priority. The provider had processes for staff to report incidents, near misses and safety events.

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.

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.

There were systems in place for processing information relating to new patients. The service worked with other providers to deliver shared care and when patients moved between services.

Referrals 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.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations.

The service did not always work with people to understand and manage risks. The care they provided did not meet the needs of people and was not always safe and supportive. The approach did not always enable people to do the things that mattered to them.

A defibrillator was stored in a clinical room, while the oxygen was stored in the reception area for ease of access. Storing emergency equipment in separate locations could lead to delays in responding to medical emergencies. This highlighted a lack of oversight in ensuring emergency equipment was stored together in a way that supported timely access during an emergency.

Some emergency medicines that are recommended for current practice were not kept at the practice. There was no written explanation or assessment to show why these medicines were not needed. This could put patients at risk if those medicines were required in an emergency. The clinical lead GP was keen to address these missing medicines on the day of inspection and advised that a review would occur.

Staff told us they regularly checked the stock levels of emergency medicines and expiry dates for all medicines. However, there were no records to demonstrate that regular checks of emergency medicines were being carried out. This meant the practice could not provide assurance that emergency medicines were consistently monitored to ensure they were safe and fit for use. With the defibrillator there were also no records to demonstrate that regular checks had been completed to ensure it remained in working order. The practice, since inspection, has put these logs in place.

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.

The service did not always detect and control potential risks in the care environment. They did not always make sure that equipment, facilities and technology supported the delivery of safe care.

The provider highlighted that the emergency lighting in the building was working but was not up to standard. There were cables in the main patient access areas, there was a broken mirror in the patient toilet. There were carpets in the main patient waiting area, the carpet was not on the cleaning schedule.

To the exterior of the building there were soffits which were hanging down in 2 separate places, 1 near the main entrance to building and 1 to the side of the building. Following the inspection the soffits were made safe with an action plan in place with a timeline advising when they would be replaced.

The guttering that ran along 1 side of the building appeared to be full, causing it to overflow, which was the potential cause of damp we noted during the inspection in one of the clinical rooms as well as flooring coming away from the wall. The provider advised that these had been cleared out following inspection.

Fire Risk Assessments and Health and Safety Risk Assessments had been carried out by the provider and actions plans were in place, however not all the concerns raised on inspection had been identified, and although the risk associated with the emergency lighting had been identified in January 2025 as part of the fire risk assessment, this was highlighted as a priority with work to completed within one month, the work had yet to be completed. Following the inspection an updated action plan was provided?

There was ramp access for wheelchair users into the building entrance, access from the car park on to the path was difficult, with no means in place to get up onto the kerb. There were places where a wheelchair could get access to the path but with no ramp it made it difficult. This aspect made accessibility for wheelchair users difficult. There were automatic doors into the building.

In most of the clinical rooms, there were exposed pipes from the central heating system, when the heating was on, this posed a potential risk to people who may touch the pipes if left uncovered.

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

The service made sure there were enough qualified, skilled and experienced staff, who received effective support and development. They worked together well to provide safe care that met people’s individual needs. However, the systems in place to support staff supervision were not effective.

There were a range of clinical and non-clinical roles within the practice. We found training was up to date, however, learning needs and development of staff was not always managed appropriately, clinical supervision took place but there was no effective system in place to record the supervision that had taken place.

Staff were working within their agreed areas of competence. Safe recruitment practices were followed.

The appraisal process for the administration staff was in place, but we did not see this for clinical staff on the day of the inspection. The provider assured us that the appraisals would be completed within 12 months.

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

The flooring in one of the clinical rooms was coming away from the wall and there was an issue with some of the sinks having overflow holes which are a potential source of bacteria.

There were unclean surfaces in some of the rooms, trollies that would be used to hold equipment to take samples from service users were dirty.

There was one clinical room where there was shelving which was covered in dust. In the same room, there was a metal stainless steel sink with cupboards above and below. The sink was not clean, there was a stain around the plug, the shelves in the cupboards were not clean, there were cracked wall tiles around the sink. These issues had not been identified by the infection prevention and control audit. Some of the desks in the clinical rooms were in bad repair, making it difficult for them to be cleaned effectively.

There was a rota that was followed for the cleaning of the practice. The practice had a designated infection, prevention and control lead, all staff were aware of who this person was. All staff had completed relevant Infection Prevention training. There was a cleaning schedule in place that was followed by staff cleaning the premises.

Since completing our onsite inspection, the provider put in place remedial works and we have been advised that some of these actions have been completed to mitigate some of the risks.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Medicines at the practice were stored securely, and medical gases such as oxygen were stored safely with appropriate safety risk assessments completed.

Fridges used to store medicines had daily temperatures recorded. We observed only a few missed daily temperature logs, meaning a process was in place to log fridge temperatures.

The practice did not manage prescription stationery securely, and in line with national NHS guidance. Paper prescriptions were not tracked safely within the practice, which could increase the risk of misuse or prescription fraud. This indicated a lack of effective systems to protect against potential prescription fraud.

We saw staff had the appropriate authorisations to administer medicines under Patient Group Directions (PGD).

As part of our assessment, we conducted a series of remote clinical searches of patient records. We looked at patients with asthma who had received two or more courses of rescue steroids within the last 12 months. Of the 5 records reviewed, 4 patients had not received a follow-up review. This meant the provider had not ensured patients at higher risk of asthma deterioration were being regularly assessed in line with national guidance.

We also reviewed the prescribing and monitoring of a medicine that can be harmful if not taken correctly, so regular monitoring and clear instructions are essential. We found examples where the day of the week the medicine should be taken had not been recorded, and shared care agreements were missing. This increased the risk of unsafe prescribing and administration.

For patients prescribed a medicine that can cause serious harm to an unborn baby if taken during pregnancy. We found that 3 out of 5 patients we looked at had not been provided with information about the potential risks. This meant the provider could not demonstrate that patients had been appropriately informed as part of shared decision-making.

39 patients were taking a medicine (bisphosphonate) used to strengthen bones and reduce the risk of fractures for more than five years. We identified that 4 out of 5 that we looked at had not been reviewed. National guidance recommends periodic review to assess continued need and minimise long-term risk.

When we reviewed records for medication reviews, we found these had been completed appropriately, and no concerns were identified in the records we checked.

The provider had effective systems to manage and respond to safety alerts and medicine recalls.

The clinical lead GP was made aware of all the above concerns with the searches and has since begun a review of all affected patients. However, this action was only taken after our intervention, indicating a lack of effective clinical oversight and systems to proactively identify and address these safety risks.

We could not be assured that clinical staff always took steps to ensure they prescribed antibiotics appropriately to optimise care outcomes. Prescribing data reviewed as part of our assessment showed that the number of antimicrobials issued by the provider was higher than local and national averages. There was a programme of regular clinical audits of prescribing, and it was reducing, but had not met national levels.

On inspection, it was found that a staff member was taking patients’ repeat prescription request forms home to work on. This could put patient privacy at risk, as the information was being taken out of the secure setting of the GP practice. We were not assured that the appropriate risk assessment and safeguards for this process were done, as staff could not tell us what happened to the repeats once they left the practice, and how they ensured the safety of patients’ information.

Clinical supervision (support and guidance given to healthcare staff) was taking place verbally; however, it was not formally recorded. The lack of documented supervision meant the practice could not demonstrate how it supported staff development, maintained clinical competence, or identified learning needs. This limited the ability to monitor and evidence the effectiveness of clinical oversight and support.

Staff informed us that practice meeting minutes were not shared with clinical staff who did not attend the meetings. This would limit staff’s opportunity to stay informed about important discussions, decisions, and updates affecting clinical practice and patient care.