Trinity 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 81 (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 complete honesty. We saw the service actively listened to concerns about safety and thoroughly investigated and reported safety events. Lessons were always learnt to continually identify and improve services.

We saw that principles of continuous learning and quality improvement had been embedded across the service at all levels. Patients were supported to raise concerns. Information about how to raise concerns and complaints was available on the service’s website within a complaints leaflet.

During interviews and discussions with staff we found that they had a good understanding of how to support patients who raised concerns, and knew how these should be recorded. In the previous 12 months the service had received 19 complaints. We examined 2 of these in detail and saw that they had been handled appropriately, and informed patients of escalation routes they could access should they remain unhappy with the outcome. Complaints we reviewed were thoroughly investigated, and we saw that learning from them was used to improve services. For example, a recent investigation had led to changes in the provision of informed consent and chaperone usage.

As well as learning from individual events and complaints the service undertook periodic reviews to identify themes and trends. For example, a thematic analysis of events and incidents recorded from 1 April 2025 to 31 March 2026 showed that of 240 incidents recorded 62% had been classified as being administrative in origin (booking, scheduling, referral/task-handling and system/rota errors). Of these 98% were recorded as either a near miss or that there was no resultant harm. Only 2 of the 240 incidents or events were assessed as causing moderate or higher harm. When required we saw that the service had made necessary statutory notifications to the CQC. Learning from individual incidents and the thematic assessment work was also shared with staff to improve performance and prevent recurrence.

Leaders and managers encouraged staff to raise concerns when things went wrong and record these as significant events. These events included near misses and identified potential system failures. There was dynamic sharing of incidents, complaints and other learning events. For example, learning events including were discussed at weekly clinical meetings, and at the provider’s quarterly Quality Assurance Committee. We saw that learning was effectively shared with both substantive and sessional staff via a monthly bulletin. Learning was also discussed with partner organisations when required. Individual feedback and reflection was also supported by the provider to promote learning. Patient feedback was also assessed, and we saw that this feedback was discussed at the meetings such as the weekly clinical services meeting as an aid to identifying developing issues and promoting learning and service improvement.

Continued learning and service improvement was further supported by a programme of clinical and non-clinical audits which included prescribing audits and assessments of clinical consultations. We also saw that the service supported individual learning which included structured events and forums, as well as ad hoc training and development for staff.

Staff informed us that they felt able to raise adverse incidents and complaints with managers, and they felt there was a no-blame culture within the organisation.

We heard from the service how they proposed to develop a patient safety incident reporting framework in line with NHS guidance which it would apply to all services and projects.

The service supported staff learning such as by organising learning forums and educational sessions.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored.

There were systems in place for processing information relating to patients accessing the service. The service worked with other partners to deliver effective care, and when patients moved between services. Staff made referrals to other services when necessary and had arrangements in place to support patients who took part in their health assessment and screening projects such as their lung health programme and mining respiratory project.

The service was fully integrated into the local urgent and primary care system and provided a seamless connected pathway for patients between their GP practice and other services such as emergency departments and secondary care. There were processes and procedures in place to ensure effective communication with partner organisations including patients’ own GP practice. The service also had procedures in place to communicate results to patients who participated in the workplace NHS health checks, but who lived outside the Wakefield area.

The provider had appointed a safeguarding lead and deputy for both adults and children, and had safeguarding policies in place which were available to staff. In addition to the appointment of safeguarding leads, staff had access to a duty manager during operating hours to raise and discuss concerns, and other senior staff were also available if required. Staff had undertaken training to the level appropriate to their role.

Staff we spoke with, or received feedback from, knew who the safeguarding lead was, how to access the policies, and felt able to escalate concerns when these were identified. Safeguarding referrals were captured on the organisation’s incident record/dashboard accompanied by an incident form.

The service worked with others when safeguarding issues were raised, and we saw evidence that safeguarding concerns were discussed at meetings such as the weekly clinical services meetings.

There was a process for chaperoning during project work and health checks, and staff had undertaken training as required to undertake this task. Staff received Disclosure and Barring Service (DBS) checks as necessary, and professional registration checks were undertaken.

The service worked with patients to understand and manage risks. We saw that staff provided care to meet patient needs that was safe, and supportive.

Staff we spoke with could recognise the signs of a patient with deteriorating health, and knew of the actions to take to keep them safe, and effectively respond to the situation. Risk assessments were completed in line with guidance, and audits of clinical notes were undertaken on a regular basis to assess compliance. Care navigation staff followed a protocol to assist their identification of acutely unwell patients, and necessary actions to take once identified.

We saw from records that staff had been trained in basic life support and how to recognise the signs of sepsis and other serious concerns. Processes were in place to manage emergency situations. The service undertook a sepsis audit where a randomised sample of 40 patients who had been prescribed antibiotics during their appointment had their consultation notes assessed to identify whether relevant observations had been recorded to highlight possible signs of sepsis. The audit was completed quarterly, with results being shared in the team bulletin and summary learning points shared with individual clinicians.

Clinicians we spoke with confirmed that patients were provided with safety netting advice relating to risks related to their condition, and actions to take if their condition deteriorated.

The service worked to identify and control potential risks within the care environment. They ensured that equipment and facilities supported the delivery of care and kept both patients and staff safe. The service had put policies and processes in place which supported the safety of staff and patients. Health and safety was included as part of the induction process for all new staff, and our checks of records showed that staff were up to date with essential training such as fire safety.

The provider worked closely with local GP practices when services such as workplace health checks and respiratory checks were delivered in outreach locations, to gain assurance that necessary health, safety, and welfare measures were in place. In addition, the service undertook safety risk assessments for all outreach locations.

During our onsite visit to the main Trinity Medical Centre site, we found it to be well maintained, and saw evidence that regular safety testing had been undertaken such as checks on fire extinguishers.

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

The service made sure there were always enough qualified, skilled and experienced staff, who received thorough support, supervision and strong development opportunities. They worked together well to provide safe care that met people’s individual needs.

Recruitment processes were in place. We found that recruitment records were comprehensive and complete, and included checks on qualifications and registrations, references, and disclosure and barring service clearance. These processes applied to both substantive and sessional staff.

We saw that induction processes were in place for new starters. This was supported by an induction policy that was detailed and included initial induction procedures, mandatory and role specific training, and ongoing supervision and review. New clinical staff had enhanced supervision and reviews of up to 3 of their sessions during their probationary period. The service maintained a weekly plan which ensured staff had appropriate site inductions.

The service had an extensive audit programme in place to test and give assurance regarding staff safety, effectiveness and decision making. This included an audit based on the Royal College of General Practitioner’s urgent and emergency care toolkit and is used to assess consultations. A full audit cycle of all GPs and advanced nurse and care practitioners was completed annually. Other audits included practice nurse and healthcare assistant audit, audits regarding projects, and reception call audits. Results and learning were again shared with staff via routes such as the monthly team bulletin and during supervision sessions.

Subject to their roles, staff had regular appraisals and supervision sessions including one-to-ones and group sessions, and these processes were embedded within the service. Training sessions were also made available to staff to keep up to date. The service also asked GPs for evidence of their yearly appraisal. This approach was confirmed by staff that we spoke with or received questionnaire responses from during the assessment. The service had developed policies, protocols and guidance which supported areas of work including safe and effective prescribing.

Staff we spoke with told us that they were able to access advice and guidance from more senior staff or the duty manager when they required it, or could access this remotely via the GP Care Wakefield App.

The service had forward planning and rota management measures in place which ensured that there were enough qualified, skilled and experienced staff on duty, this included planning staffing rotas in advance. Workforce planning considered future service demands, and we saw that the service tightly monitored appointment utilisation. Recruitment was planned, and was based around existing service demand and the needs of new and developing services. This included the development of new competencies for staff to enable them to safely and effectively deliver services. Where staffing levels could not be maintained, the service would implement their business continuity plan.

The clinical assessment service was in part delivered via a sub-contract, with GPs and advanced nurse practitioners being available to support the sub-contracted clinical advisors. We saw that the service had gained assurance from the sub-contracted provider that their staff had the necessary qualifications, competencies and training to deliver their roles safely and in line with guidance.

The service had measures in place to manage infection prevention and control (IPC) across all its delivery sites. This included the appointment of trained staff members to act as the service’s IPC lead and deputy, and the development of an IPC policy which was kept regularly updated. IPC compliance assessment was supported by checks and audits which assessed the levels of operational compliance against standards. Additional processes were in place which supported good IPC practice, this included procedures for the cleaning and disinfection of equipment. The provider liaised closely with the partner organisations which acted as host sites for project delivery to gain assurance that IPC management measures were in place and were effective.

Staff undertook IPC training during their induction, and annually thereafter. We saw that as part of the recruitment process the provider had assurance that staff had received the necessary immunisations and vaccinations to undertake their roles safely.

Our onsite visit to the main site found it to be clean, and in a good overall structural condition.

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. Prescribing could be undertaken for patients who accessed the clinical assessment service, and for those patients who participated in the mining respiratory project.

Safety netting processes were in place, and patients were told who to contact if their condition did not improve or if they experienced any unexpected symptoms.

We saw that the service had developed protocols to support effective medicines management and that oversight and management processes were in place.

The service had effective systems to manage, receive, record and respond to safety alerts and medicine recalls. Staff were informed of alerts and changes to medicines guidance and best practice.

The service monitored and audited prescribing, and ensured that staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics and Controlled Drugs. Findings from audits were shared with staff. Significant events regarding medication were recorded and investigated. We were informed that the service regularly worked with their Integrated Care Board’s medicines management team and acted on feedback.

A review of consultations during our site visit indicated that prescribing was in line with guidance.