Two Rivers 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. At our last inspection we rated this key question as good. At this assessment it was rated requires improvement. We found that the service did not always provide safe care because people did not receive appropriate monitoring and review of their prescribed medicines. There was a backlog of people’s notes which required summarising. However, there was a culture of learning from safety events and when things went wrong, staff acted to ensure people remained safe. Recruitment checks were carried out in accordance with regulations and new staff received an induction to their work. There was oversight of the work of clinical staff working in extended roles.

The provider was in breach of legal regulation in relation to safe care and treatment.

This service scored 62 (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 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.

We received no specific feedback from people regarding their experiences for this quality statement. Representatives from the Patient Participation Group (PPG) told us the practice leaders listened to concerns and gave examples of when improvements had been made.

There were processes for staff to report incidents, near misses, safety events and complaints. Systems were in place to record and investigate these events, identify what went well, what could have been done better, identify learning, and make any improvements required. Learning event meetings were held approximately every 4 months where events were discussed and reviewed and action points agreed. We reviewed a sample of the minutes of learning event meetings which were shared and available for all staff. Actions identified had all been completed. Managers encouraged staff to raise concerns when things went wrong, and staff apologised and gave people support.

All clinical staff and the majority of non-clinical staff told us they knew how to identify, and report concerns and were informed of subsequent learning. Some staff shared examples of improvements made following incidents and complaints that improved care for others. For example, ensuring referrals for suspected cancer were sent correctly was added to the daily tracking system.

There were systems in place for processing information for people registering at the practice, which included for example, homeless people and temporary residents. However, we noted they had a backlog of 1186 people’s notes which required summarising. (Summarising is the process of extracting an accurate medical history from the medical notes of a new registered person.) In response, the practice submitted a risk assessment and action plan to address this backlog. This advised people’s records had an alert if they had not been summarised, and if the notes were needed, they were summarised within 24 hours. A GP Partner had audited a range of people’s notes awaiting summarisation, for example, those who had waited the longest for summarisation and found relevant medical information present in their electronic record, but no summarising code had been recorded. The provider’s plan included arrangements to ensure delayed summaries were prioritised and the backlog addressed. This included additional staffing support being brought into the admin team, to enable trained summarising staff to focus on summarising and recruiting a summariser to assist with this work.

Care home representatives confirmed people who had recently moved into a care home were both registered with the practice, and received a health check by a clinician in a timely manner. They gave positive feedback in relation to timely, appropriate referrals being made, and being able to self-refer to some services. We received mainly positive feedback from people which related to the management of test results and referrals.

Staff told us they had the information they needed to deliver safe care and treatment. Protocols were in place to manage the flow of work within the practice. This included for example, how results for a range of tests were filed, which a GP Partner confirmed were reviewed regularly. People’s correspondence which was deemed urgent, for example scan results and ambulance reports were prioritised. Arrangements were in place to ensure required actions were reviewed and authorised by an appropriate clinician. The requesting clinician managed test results. We reviewed the task lists on the clinical system which showed they were managed in a timely way. Arrangements were in place to ensure that when a clinical colleague took leave, their tasks were appropriately delegated and acted on.

Monthly audits of the work of non-clinical staff were undertaken by practice leaders to monitor that people’s correspondence was dealt with in a timely way and to monitor demand and capacity. Issues where guidance and processes were not followed were also identified and learning undertaken. Spot checks were also completed but not documented and practice leaders advised they would document these.

Staff made sure there was continuity of care, which included when people moved between different services. Staff who were involved in making referrals were clear about their role and daily checks were in place to ensure people who had been referred for suspected cancer had attended their appointment, and follow up arrangements were in place. The practice had fail-safe systems to ensure all cervical cytology results were received from samples sent. They also had systems to audit and follow up people who had an abnormal result and set up alerts to recall people. The service also worked with other providers to deliver shared care and when people moved between services.

We received positive feedback from partners in relation to ensuring safe systems of care, including when people received care and treatment from a range of services.

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. People who provided feedback for this assessment had no specific views or concerns in this area.

Staff we received feedback from told us they had received training in safeguarding children and adults, were confident to report any concerns and knew who the safeguarding leads in the practice were. Safeguarding policies were in place and known to staff. However, in the practice policy we found the training levels for some staff were not at the right level, and training records confirmed this. Practice leaders acted on this and following the site visit submitted an updated policy and confirmed staff had now completed training at the level relevant to their role.

The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations. Safeguarding meetings were organised by the Care Coordinator and all staff were invited to share items for inclusion on the agenda. The Care Coordinator reviewed people’s clinical notes, and this information was available at the meeting to update all clinicians. There was oversight of this work by a named GP Partner. The practice held bimonthly meetings where safeguarding discussions took place. We reviewed minutes of practice safeguarding meetings. People’s needs were discussed and reviewed and actions agreed and followed up. Multidisciplinary meetings were also held on an individual basis, when necessary.

Arrangements were in place to follow up vulnerable people who had not attended for their appointment, which included for example, post-natal and secondary care appointments. A GP reviewed all Emergency Department attendances or admissions by children.

We received positive feedback from partners regarding internal safeguarding arrangements and practice staff attendance and engagement in external meetings, which included safeguarding administrators.

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.

People who provided feedback for this assessment had no specific views or concerns in this area.Care home representatives told us practice clinicians involved people, their carers and family, as appropriate, to ensure care and treatment met individuals’ needs and preferences.

There were effective arrangements for supporting people to identify, mitigate and manage risks. The practice had guidance and templates for staff to identify, assess and manage people whose health was deteriorating, and for managing medical emergencies. All staff told us they could recognise people whose health was deteriorating and knew of action to take. This included immediate advice to give people and how to escalate risk to an appropriate clinician. The practice had a duty GP every day who was available for advice and support as necessary. The majority of staff had completed sepsis awareness training. The majority of staff had completed basic life support and anaphylaxis training relevant to their role and those who had not, were booked onto training in June 2025. The practice had risk assessed which emergency medicines and equipment to have on site. There was a system in place to monitor stock levels and expiry dates of emergency medicines. These were checked on a weekly basis and documented.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

All staff we received feedback from told us there were systems, practices and processes to keep people and staff safe. Staff had suitable and sufficient equipment to undertake their role and were satisfied with the health and safety arrangements in place.

Arrangements were in place to ensure the premises were maintained. The practice used a range of risk assessments to identify, manage and mitigate risks. Issues identified from risk assessments and safety checks were shared and discussed with the GP Partners and management team. Most recommendations had been acted on, and where recommendations had not been completed this was monitored. We noted water temperature checks which were out of range had been escalated to an external company who advised these were acceptable. The practice advised they would update this information on their checklist. Ongoing checks relating to fire safety, electrical safety and equipment calibration were also completed. The practice had an up-to-date business continuity plan which identified a range of risks and how they would be managed.

During the site visit, we observed fire exits were clear and fire safety equipment easily available and checked by an external company. We noted actions identified in the fire risk assessment, general risk assessment and wheelchair risk assessment had been completed. For example, instructions on how to reset the fire alarm panel had been put in the fire marshal bags, work had been completed on an emergency escape door to ensure it closed securely and monthly checks of the wheelchair were in place. People in the waiting room were easily visible to staff so they could identify and respond to any people whose health may be deteriorating.

The practice used technology securely and effectively and conformed to relevant digital and information security standards with arrangements in place for the confidentiality of data management.

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.

Feedback from people was positive in relation to the knowledge, skill and competency of clinical staff. Representatives from care homes were also positive about the knowledge of clinical staff and the clinical care provided.

The practice had systems and process for safe recruitment and had responsibility for the recruitment of staff employed in the North East Ipswich Primary Care Network (NEIPCN). We reviewed 2 staff personnel files and found appropriate recruitment checks had been carried out, which included Disclosure and Barring (DBS) checks. DBS checks were in place for staff who acted as chaperones, and they had completed training for this role. The professional registration of clinical staff was checked at recruitment and on an ongoing basis. All new staff received an induction, adapted to their role.

Staff told us there was an effective induction system for permanent and temporary staff tailored to their role. Staff told us they received sufficient training, there was oversight of their work, and they had regular appraisals.

The practice were currently streamlining their process to improve oversight of the completion of training deemed mandatory by the practice. We noted gaps in completed training, for example with basic life support, learning disability and autism awareness, fire safety and infection prevention and control. We raised this with practice leaders who acted and at the time of the site visit, most of the training deemed mandatory by the practice had been completed or a date had been booked. Practice leaders continued work to improve the oversight of the completion of staff training.

The practice was able to demonstrate staff had the skills, knowledge, and experience to carry out their roles. Staff who were responsible for long term condition reviews, childhood immunisations and cervical screening had received specific training, and their competency was checked on an ongoing basis. Arrangements were in place for the clinical oversight of staff working in extended roles, which included those who prescribed medicine. There was regular documented review of their practice, supported by peer review and protected time for case discussions. A duty GP was available for clinical advice and support. There was oversight of the completion of staff appraisals. The majority of staff had already received an appraisal, and other staff had these booked.

To ensure sufficient staff were available, the practice minimised the number of staff who were off work at any one time. Some staff were multi-skilled and worked flexibly in response to peak times of demand from people using the service, and to minimise the impact of unexpected staff absence. There were ongoing plans to recruit a Care Navigator and an NEIPCN Clinical Pharmacist. The majority of staff told us there were sufficient staff.

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.

Feedback we received from people was positive in respect of the cleanliness of the practice environment. Feedback from people who had undergone minor surgery was obtained by the practice and showed high satisfaction regarding cleanliness and hygiene.

The practice had a Lead Nurse and Health Care Assistant support for infection, prevention and control (IPC) who had some protected time to undertake their role and attended regular update meetings. They also had a lead GP Partner for IPC. The practice were in the process of changing from paper records to electronic records and were using updated audit schedules, forms and templates to assess and monitor IPC standards to identify areas for improvement. An internal IPC audit completed in April 2025 had an overall score of 96% compliance. There were systems to share IPC related issues, which included recommendations from audits, however arrangements to follow up on actions to ensure they had been completed were not always clear. This had been identified and IPC leads planned to set up tasks as reminders, for example when curtains needed to be changed. Further improvements were planned and to embed the new processes in place. Improvements had been made over the past year, for example, signed IPC policies were available electronically for staff, and new cleaning logs for equipment including for example, spirometers, ambulatory and home blood pressure monitors, and toys.

During our on-site visit, we observed the practice to be clean and tidy. We saw documented checks of cleaning and arrangements in place to effectively communicate with the external cleaning company and resolve any issues. There were records of cleaning of equipment. Appropriate arrangements were in place to manage clinical waste. We checked a sample of actions identified from an audit of rooms undertaken in April 2025 and found they had been completed.

Policies and guidance were available for staff and at the time of the site visit, all staff had completed training relevant to their role. Staff told us they had no concerns regarding infection, prevention and control (IPC) and told us about the systems in place for safely dealing with clinical specimens and spilt bodily fluids. Staff immunisation history was documented; however, we noted there were some gaps in their overview spreadsheet. Some staff had been referred to occupational health, some staff were getting immunisations up to date, and some staff had a completed risk assessment. We raised this with practice leaders and were advised the lead nurse planned to develop a policy for staff immunisation to support effective oversight.

The service did not make sure that medicines and treatments were safely monitored. People did not always receive appropriate monitoring and review of their prescribed medicines.

As part of our assessment, we carried out remote searches of clinical records to check how the practice monitored people’s health in relation to medicines. We identified 98 people prescribed an immunosuppressant medication, of which 12 people were identified as not having the required monitoring. We reviewed a sample of 5 people’s records and found appropriate monitoring was in place. However, we found people’s health was not always monitored in a way that ensured the safe prescribing of certain medicines. For example, we identified 833 people prescribed medicines that prevent blood clots of which 465 people potentially had not had the required monitoring. We reviewed 5 and all of those had overdue monitoring. At the site visit we found the renal function of 351 of those people had been assessed as a recent weight and blood monitoring was available. The remaining people had been sent a questionnaire to request an up-to-date weight and those who needed blood monitoring were being followed up by the medicines team who then planned to assess people’s renal function. They planned to set up a repeat audit to check monitoring was up to date.

Another search found 518 people prescribed medicines which were addictive and needed regular review. Of these people, 224 potentially had not had a medicines review in the last 12 months. We reviewed a sample of 5 people’s records and found 4 people were overdue a dose review and 4 people were overdue a medicines review. At the site visit we found these people had all had a medicines review. The notes of all identified people had been reviewed, and 120 people had been seen or reviewed by secondary care services and 73 people had already been reviewed at the practice but had not been coded using a code recognised by our search. The GP Partners advised work would continue to ensure people identified through the clinical searches we had carried out as part of the assessment process would receive the appropriate monitoring. Additional audits had been set up to ensure the required monitoring was completed as part of their arrangements for the safe management of medicines.

A further search identified 175 people prescribed medicines to manage conditions like hypertension, heart failure, and chronic kidney disease, of which 38 people potentially had not received the required monitoring. We reviewed a sample of 5 people’s records and found 2 of those had not had the required monitoring. The GP Partners advised they had already identified this issue and were working to ensure monitoring was up to date. At the site visit we found 15 people had since had the required monitoring, and 23 people had been invited to have blood monitoring. A repeat audit had been set up to check monitoring was up to date.

We reviewed the quality of medicines reviews and sampled 5 people’s records. We found 2 people’s medication review did not document the context for the review. The GP Partners advised they had raised this with clinicians who undertook medicines reviews. Through our clinical searches, we also found some people were overdue a medicines review. This had already been identified and was documented on the practice risk register. The GP Partners advised clinicians had been encouraged and reminded to use the medicines review template to ensure compliance and monitoring was documented. People prescribed multiple medicines or those with a long-term condition were sent a medication review questionnaire in their birth month which were reviewed by the medicine management team. Practice leaders were confident they had sufficient staff capacity to catch up with overdue medicines reviews, and advised they needed to restructure this area of work and ensure all staff took ownership which they were in the process of managing.

We received mixed feedback from people in relation to medicines management. The repeat ordering process worked well, although medicines queries were not always responded to in a timely way. Most care home representatives told us people’s medicines were reviewed, the repeat ordering process worked well, and staff answered and dealt with any queries effectively.

We found Patient Group Directions (PGDs) were in place to allow nurses to give vaccinations without a prescription and examples we reviewed had been appropriately authorised for use within the service. An audit of PGDs had also been completed and actions taken to improve compliance which included for example a contact page to update and track as new PGDs were released.

During our onsite visit we observed arrangements were in place to manage medicines safely. Medical gases were stored safely with appropriate signage in place. Vaccines were appropriately stored, monitored, and transported in accordance with national guidelines and medicines that required cold storage were being appropriately kept within temperature monitored fridges. Immediate arrangements were in place if temperatures went out of range. Staff regularly checked the storage temperature, stock levels, and expiry dates for all medicines, including emergency medicines and vaccines. Prescription stationery was stored securely, and the system to monitor prescription stationery was effective.

We reviewed a range of prescribing indicators, which included for example, antimicrobials, antipsychotics, hypnotics and antibiotics. The practice were within the expected range for prescribing these medicines.