Christchurch Medical Practice

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 has changed to 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. Learning from incidents and complaints resulted in changes that improved care for people.

Staff were encouraged to raise concerns when things went wrong. They told us significant events, complaints and examples of feedback were shared and discussed during regular staff meetings. Staff felt there was an open culture and understood their duty to raise concerns and report incidents. Staff apologised and gave people support in line with the duty of candour. Leaders provided examples of how incidents were investigated and resolved.

There were policies and processes to record, investigate and act on incidents and complaints. These were discussed in monthly governance meetings and minutes made available to staff who were unable to attend.

The service did not work well with people and healthcare partners to establish and maintain safe systems of care. They did not manage or monitor people’s care effectively, including when people moved between different services.

Although staff were aware of their responsibility to monitor and manage administrative workflow, systems were not effective in ensuring important information was reviewed and acted upon in a timely way. During our review of the service’s clinical system, we found 5,001 documents awaiting review and filing, including hospital discharge letters, accident and emergency correspondence and people’s registration information. We also found 352 unactioned workflow tasks, including death notifications and correspondence from other healthcare providers, such as pharmacy, hospital, NHS 111 and GP out-of-hours. Although the service was in the process of seeking external support to manage the backlog, the volume and nature of these unactioned items meant the service could not be assured important information was reviewed and acted upon in a timely way. This increased the risk of delays to treatment, follow-up and decision making, and meant people may not always experience safe transitions between services.

Feedback from the local community mental health teams (CMHT) identified concerns about the quality of referrals generated by the Primary Care Network (PCN), which the service was part of. The PCN had ceased arrangements for oversight of vulnerable people through a mental health multi-disciplinary team (MDT) in September 2025.Replacement arrangements were not yet established at the time of assessment. This meant there was a risk that vulnerable people may not receive timely support and concerns requiring escalation may not be identified promptly. However, service leaders told us they were working with Dorset HealthCare as part of a newly developed integrated neighbourhood team. This team brings together a multi-disciplinary group combining local health, social care, and voluntary organisations to provide joined-up care focused on the needs of local people. The service in conjunction with the local primary care network (PCN) had committed to jointly funding 2 mental health practitioners, providing oversight to support the implementation of a monthly mental health MDT, with the aim of providing earlier treatment interventions, but this was yet to be implemented at the time of assessment. People were involved in decisions about their care, and their preferences of treatment was documented in their My Wellbeing Plan or care plan letter. Both of which were shared with the service following CMHT consultations, such as specific medicine reviews or follow-up reviews at monthly intervals.

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.

There were designated safeguarding children and adult leads at the service. There were multi-disciplinary team (MDT) meetings where safeguarding issues were discussed, and these were attended by clinical and management staff. External stakeholders were invited to safeguarding meetings where relevant, such as health visitors. Systems were in place to appropriately refer people to the local authorities and information was shared amongst community nursing teams where required. Safeguarding and chaperoning policies were in place and accessible to staff. A review of the service’s clinical system, which formed part of this assessment, indicated reports and requests to support local authorities in relation to safeguarding children and vulnerable adults were managed appropriately and in a timely manner. There were processes to follow-up people who frequently did not attend appointments to evaluate any safeguarding risks, such as those who were vulnerable, frail or children. Staff demonstrated an understanding of their safeguarding responsibilities and knew how to escalate concerns when required.

A mixture of clinical and non-clinical staff members had chaperone responsibilities as part of their role. Those staff members had completed Disclosure and Barring Service (DBS) checks to ensure they would be appropriate to undertake this role.

The service worked with people to understand and manage risks. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. The service had maintained emergency equipment and staff were aware of procedures including recognising a deteriorating person and were trained on relevant actions to take. People were advised on risks related to their condition and actions to take if their condition worsened.

Leaders told us abnormal results were prioritised to ensure people were followed up in a timely way. For example, we reviewed the service’s pathology clinical system mailbox and noted abnormal results were assigned either to the requesting clinician or to the duty GP for review on the day and correspondence was picked up via the GP partners, in line with service policy, to prevent delays to care and treatment.

The service was supported by care co-ordinators and a social prescriber within the local primary care network (PCN). These roles ensured people’s care was supported by other local healthcare services such as secondary care providers and community initiatives. In particular, for those with complex health and care or social 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.

We noted risk assessments had been carried out for people using the service, staff and the environment. For example, personal emergency evacuation plans (PEEPs), protecting pregnant employees, display screen equipment (DSE), lone working and ‘employee wellbeing plans’, which were coordinated with occupational health where relevant.

Health and safety risk assessments had been undertaken to identify and mitigate any environmental hazards, including a ‘disabled person environmental audit’. The service assessed environmental risks and took action to make the premises safer and more accessible for people using the service, including improvements to toilet facilities, and an widened entrance access for wheelchair users.

Equipment, including portable appliance testing, calibration and fire safety equipment servicing was maintained in line with servicing scheduled. The service had a business continuity plan which was monitored and reviewed regularly, as well as a risk register which identified and monitored action to mitigate risks, including trip, slip and fall hazards.

The service had systems to recruit, induct and train staff, however these were not always fully effective in ensuring staff received appropriate clinical supervision and oversight.

We found staff mandatory training was completed to 92% compliance, there were several staff who had not completed relevant modules. However, following our site visit, the service submitted evidence which demonstrated an improved compliance rate of 95%. The service had processes to monitor training, including discussion at team meetings and automated reminders for expiring modules. However, the training policy did not specify an expected compliance target for all employed staff. As a result, leaders could not be fully assured that all staff had completed the mandatory training required to carry out their roles safely and effectively.

Although staff told us they could discuss prescribing and treatment planning queries with leaders, clinical supervision and audits of non-medical prescribing were not always provided in line with national guidance or service policy. Although individual cases were discussed to support safe decision-making and help reduce the risk of prescribing errors, records of supervision and audit discussions were not held and maintained by the service.

We carried out a review of the service’s recruitment checks in relation to 3 members of staff and determined recruitment and Human Resource (HR) records were maintained in-line with service policy and Schedule 3 requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Staff received a formal induction relevant to their role and responsibilities and were supported through ongoing appraisals. The service had named supervisors for the medical students at the service under their education placements. Staff told us the service ensured staff were supported in their roles. Clinical education sessions were also held regularly, which involved external secondary care leaders to support staff in upskilling their knowledge in providing various care and treatment.

There were arrangements to ensure risk associated with emergencies and lone working were mitigated.

The service did not always assess or manage the risk of infection effectively. They did not always detect and control the risk or share concerns with appropriate agencies promptly.

Although the service had a designated infection prevention and control (IPC) lead and completed audits of hand hygiene and personal protective equipment (PPE), it did not have a comprehensive process for monitoring environmental IPC risks and ensuring actions identified through audits were completed. The 2025 IPC audit did not demonstrate that all actions identified had been monitored or completed.

Although the service’s annual legionella assessment identified no legionella bacteria in the premises, hot water temperatures were recorded below 55 degrees Celsius. Hot water temperatures at source are required to be maintained at approximately 60 degrees Celcius to reduce the risk of bacteria growth. During our site visit, the service could not demonstrate actions identified in the assessment in October 2025 had been completed or water temperatures had returned to recommended levels. This meant there was an increased risk of legionella bacteria growth.

The service had not retained all Control of Substances Hazardous to Health (COSHH) risk assessments and relevant Safety Data Sheets (SDS) for all cleaning products stocked. The service provided evidence had been addressed following our site visit.

However, we found the premises was visiblly clean during our site visit and cleaning schedules were reviewed with the external cleaning contractor. Clinical waste arrangements ensured safe storage and appropriate labelling in line with IPC national guidelines.

The service did not ensure medicines and treatments were safe and met people’s needs, capacities and preferences.

During our remote clinical searches, our findings indicated not all people who had been prescribed certain medicines, had been appropriately monitored and reviewed in line with national guidelines. For example,134 people were identified as having had 10 or more benzodiazepines (used to treat anxiety, insomnia and seizures) or z-medicines (sedative-hypnotic medicines used to treat insomnia) prescribed within the last 12 months. We reviewed a random sample of 5 people’s records and noted none had been reviewed to ensure an effective dosage reduction management plan was in place, and a medicine review completed in line with national guidelines. It was also unclear whether the prescriber had checked it remained appropriate for the medicine to be authorised safely.

We also reviewed 4 people who were prescribed Leflunomide (a disease-modifying antirheumatic drug (DMARD) used to treat active rheumatoid arthritis). Of these, 3 people had not received all recommended monitoring, including an up-to-date weight, blood pressure and blood tests, in line with national guidance, increasing the risk of harm.

Although leaders told us about the service’s system to audit safety alerts, this was not always effective to ensure actions were taken in a safe way for people. During our remote clinical searches, our findings indicated people who were affected by medicine safety alerts were not always informed of the associated risks or reviewed appropriately. For example, 89 people were identified as having been prescribed teratogenic medicines (medicine which can affect the development of an unborn baby during pregnancy). We reviewed a random sample of 5 people prescribed topiramate (a medicine used to treat epilepsy and prevent migraines) and noted 3 people had not received clear discussions regarding the risks outlined in the safety alert. Contraception had been declined by 2 people; however, there was no clear clinical decision-making or oversight to determine whether prescribing should continue in primary care or be transferred back to the secondary care specialist in line with guidance. We reviewed a sample of 5 people prescribed pregabalin (a teratogenic medicine used to treat epilepsy, generalised anxiety disorder, or nerve pain) and noted 1 person had not had risks discussed in line with the safety alert with an annual risk awareness form (ARAF) completed. In addition, 1 person had not received pregnancy prevention advice since being prescribed.

A review of medicine reviews determined that 4 out of the 5 records we reviewed did not contain sufficient information to support ongoing care and treatment planning.

However, the service held appropriate emergency equipment and emergency medicines. The service maintained appropriate fridge temperature records where vaccines were being stored and had taken appropriate action when fridge temperatures were outside of safe ranges.

Patient Group Directions (PGD) and Patient Specific Directions (PSD) were in place and relevant staff worked within these administering immunisations. Prescription stationery was logged and stored securely.