Culcheth 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 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 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

The service detected and controlled potential risks in the care environment overall.

The provider had a system in place to ensure there were regular checks of the safety of the premises and equipment. Staff and leaders completed health and safety risk assessments and undertook audits to ensure they had identified and addressed risks. The provider was not able to demonstrate that the fire risk assessment was carried out by a suitably competent person. Following the assessment the provider arranged for a specialist service to undertake annual fire risk assessments, commencing in June 2026.

Staff told us they had access to the equipment they needed and reported satisfaction with the work environment.

The service had a business continuity plan which was regularly reviewed and outlined how the service should continue to operate in the event of a disruption.

The service made sure there were enough staff in differing roles to meet the needs of patients. Staff and leaders told us how they worked together to provide safe care that met people’s individual needs.

The service employed a range of clinical and non-clinical roles, which included GPs, advanced nurse practitioners, nurses, general practice assistants, a health care assistant and a pharmacist. Overall, leaders ensured staff were up to date with their training which the service had deemed mandatory and operated within their agreed areas of competence. Some staff needed training updates and following the assessment the provider introduced improvements to monitor staff were undertaking this training in a timely way.

There were systems to support non-medical prescribing staff. However, consultation audits were not recorded to demonstrate the system to monitor competence and support. Following the assessment the provider addressed this by introducing a recording system for quarterly audits.

The service followed safe recruitment and employment procedures overall when employing staff. This included identity checks, review of qualifications and obtaining references. A regular review of professional registration following employment was not taking place. The provider told us how they would address this during the assessment.

The service assessed and managed the risk of infection and had a process to share concerns with appropriate agencies promptly.

During our onsite visit, the premises and equipment we reviewed was noted to be visibly clean. The service had cleaning schedules available, which outlined how staff should clean the building and its equipment.

A recent annual audit of infection prevention and control had been completed by an external service. In-house infection prevention and control audits were carried out but not always recorded. This was addressed following the assessment. Regular hand-washing audits were documented.

Personal protective equipment was in sufficient supply and located appropriately around the premises. Staff had completed relevant training in infection prevention and control.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.