Quarry Bank 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 assessment, we rated this key question as Good. At this assessment, the rating remains the same.

This service scored 69 (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. The provider had processes for staff to report incidents, near misses and safety events. The practice had a significant events policy, and a reporting form was in place, which was accessible to all staff members. Staff felt there was an open culture, and that safety was a top priority.

There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Information reviewed demonstrated that people had opportunities to provide feedback, and they knew how to make a complaint. Lessons were learnt from individual complaints and shared with the practice team to improve the quality of care. Feedback and information were available in the practice and on their website.

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.

Effective systems were in place for processing information relating to new people including the summarising of new records. The service worked with other providers to deliver shared care and when patients moved between services. We found clinicians made appropriate and timely referrals in line with protocols and up to date evidence-based guidance. There were systems in place to ensure all patient information including laboratory test results and referrals were reviewed and actioned in a timely manner.

The provider told us that there were processes in place that were monitored and managed to keep people safe. For example, the provider was part of the Primary Care Network (PCN) and attended regular meetings with other agencies across the locality to share and discuss information relating to patient care and treatment.

There were a range of structured meetings in place. These included safeguarding, multi-disciplinary and practice team meetings. Regular team meetings were held for all staff to have the opportunity to discuss any concerns, and the leadership team had the opportunity to discuss and share learning from incidents and complaints.

The service did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They did not always share concerns quickly and appropriately.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. The practice maintained a list of vulnerable people, however on reviewing the safeguarding registers we found that families living in the same household were not linked with children where safeguarding concerns had been identified. We also found one child who was a safeguarding concern as being registered with the practice without any family from the same household being a patient at the practice. The findings of our review were shared with the leadership team on the day of the assessment and action was taken to review and update the registers.

There was a safeguarding lead for children and adults, and all staff were aware of who to speak to if they identified a safeguarding concern.

There were processes in place to follow up children and young people who were not brought to their appointments with the provider and for secondary care appointments. A safeguarding report was run on a monthly basis to ensure the information stored by the practice was regularly reviewed and updated.

Safeguarding meetings were held every three months. Community teams were invited, and information was shared appropriately for the care of people with safeguarding and vulnerable concerns. For adult patients weekly multi-disciplinary team meetings were held with community teams.

Records we examined showed that all staff had a DBS check in place. DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable.

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.

All staff were trained in basic life support and staff could recognise a deteriorating patient. They knew of the action to take if they encountered a deteriorating or acutely unwell patient and had been given guidance on identifying such patients. Patients were advised on risks related to their condition and actions to take if their condition deteriorated. Emergency equipment was available and maintained.

The practice had registers in place to support those patients who were vulnerable or who had mobility or communication needs.

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

Health and safety related assessments and procedures to manage health and safety were in place. A health and safety risk assessment and fire risk assessment had been completed in April 2026. Staff had been provided with training in health and safety related topics such as fire safety, infection control, basic life support and resuscitation training.

There were policies and procedures in place for the management of health and safety. Fire safety policies were in place and staff were aware of how to access these. Fire marshals had undertaken additional training for the role. Systems were in place for the regular checks of fire alarms, extinguishers and fire evacuation procedures with weekly checks carried out around the building.

The practice had completed assessments in place for the control of hazardous substances (COSHH). Evidence provided by the practice showed equipment was regularly calibrated and electrical items were PAT (portable appliance testing) tested. The latest calibration of equipment had been completed in April 2026.

There was a business continuity plan in place which was monitored and reviewed. Reception and administration staff who handled calls to the practice and arranged appointments with the clinical team were aware of potential red flag symptoms. Staff knew when to notify a GP or other clinicians with concerns about a patient who may be acutely unwell and/or deteriorating.

During our site visit we found the premises were well maintained. The provider detected and controlled potential risks in the environment. They made sure equipment, facilities and technology supported the delivery of safe care. Regular checks were carried out on the premises, facilities and the equipment provided. Contracts were in place to ensure the premises were clean and well maintained. Clear signage around the building supported people and staff in the event of an emergency evacuation.

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.

Evidence provided demonstrated systems were in place for the monitoring of staff, which included regular conversations as part of their clinical supervision. We found training was up to date, learning needs and development of staff was managed appropriately and staff were working within their agreed areas of competence.

The practice had recruitment policies in place, and all staff had completed disclosure and barring checks. Records of staff immunisation status were maintained, and all staff had completed annual appraisals. New staff participated in a structured induction programme and were required to complete mandatory training within appropriate timeframes. Staff were supported to deliver safe care through access to relevant training and development opportunities. Personnel folders were well organised and there was a systematic approach to ensure that personnel folders were managed appropriately.

There were a range of clinical and non-clinical roles within the practice, and the practice was also a training site for medical students.

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.

An infection control audit had been completed to identify potential risks and take appropriate action where required. The audit had been completed in April 2026. Cleaning schedules were in place and we found random cleaning audits were completed. The latest cleaning audit had been in February 2026.

The practice had a designated infection, prevention and control lead and all staff had completed training relevant to their role. Staff were aware of the systems and processes to follow to ensure clinical specimens were handled safely.

The practice had policies in place for infection, prevention and control which was accessible to staff and staff were aware of the action to take. For example, in the event of a sharps or contamination injury.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

As part of the assessment, we carried out remote clinical searches to review how patients’ medicines were monitored and if the appropriate care and treatment was being received. We reviewed patients who had been prescribed Disease-modifying antirheumatic drugs (DMARDS) used to treat autoimmune diseases like rheumatoid arthritis. We reviewed the records of 5 patients and found that appropriate monitoring was in place in line with guidance.

As part of the assessment, we reviewed the number of people who had been prescribed medicines to reduce the risk of blood clots forming called direct oral anticoagulants (DOACs), who had not received the appropriate monitoring in the past 10 months. The search identified 142 patients on these medicines, with potentially 20 patients overdue monitoring.

We carried out a search to identify patients who had received a medication review in the past 3 months. The search identified 815 patients. We reviewed a random sample of 5 records and found whilst medication reviews had been completed in all sampled cases, the level of detail recorded in the patient records, were without the patient being present. We also found some of the patients were overdue blood monitoring and this had not been actioned.

The practice worked with the clinical pharmacists from the local Primary Care Network (PCN) to monitor people and the prescribing of medicines. The provider was able to demonstrate they had processes in place in relation to safety alerts issued by the Medicines and Healthcare products Regulatory Agency (MHRA). For example, we carried out a clinical search to identify women of childbearing age who were prescribed teratogenic medicines, which have the potential to increase the risk of birth defects. The search identified 29 patients prescribed these medicines who required a Pregnancy Prevention Programme (PPP) and an annual risk acknowledgement form. We reviewed 5 patient records and found that 1 patient was no longer prescribed the medicine, however the medicine remained on the repeat prescribing screen, 1 patient record stated they had completed the annual risk acknowledgement form, however we could find no evidence to confirm this. We discussed the findings with the clinical lead and received assurances that action had been taken where required to ensure the records were up to date. Other clinical searches undertaken in response to safety alerts demonstrated that appropriate compliance arrangements were in place for most of the alerts, however one of the clinical searches identified 17 out of 40 patients on ACE/ARB medicines plus aldosterone antagonist, medicines used for the treatment of patients with heart failure which had potential risks to cause high potassium levels were overdue monitoring.

There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.

Emergency medicines, vaccines and medical equipment had clear monitoring processes in place. There were appropriate arrangements in place for the management of vaccines and for maintaining the cold chain and a data logger was in place. We saw fridge temperatures were routinely monitored and vaccines we reviewed at random were in date and stored appropriately. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments.

People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms. Staff received regular training, were competency assessed on medicines optimisation, and felt confident managing the storage, administration and recording of medicines. Staff managed prescription stationery appropriately and securely. Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. Prescribing data reviewed as part of our assessment confirmed this. For example, the number of antimicrobials issued by the provider was in line with local and national averages.