Dr Murthy Motupalli Also known as Blackburn Road 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

The service did not demonstrate a positive learning culture, and there was limited assurance that staff felt able to raise concerns in all areas of the organisation. While leaders stated that safety was prioritised, this was not reflected in practice. Systems for managing concerns and incidents were not effective, and although some incidents were investigated, this was not always thorough or timely. Actions taken to reduce the risk of recurrence were not implemented or embedded. Although staff were generally aware of how to identify and report issues, this did not translate into effective organisational learning. Learning from incidents was not routinely or effectively shared across the whole practice, limiting opportunities for wider improvement and increasing the risk of repeated errors. Systems to monitor people’s health and review medicines were not well managed. We identified gaps in oversight and follow-up of blood results, and issues were not always addressed promptly or effectively. Processes for managing safety alerts were not sufficiently robust to ensure all relevant information was acted upon in a timely manner. While safeguarding procedures and training were in place, there was limited assurance that these were embedded in practice. We identified environmental risks such as poor infection control measures and a lack of health and safety oversight. Overall, governance systems were not effective in ensuring safety was proactively managed, and the provider could not demonstrate that risks to patients were identified, mitigated and learned from.

This service scored 28 (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 did not demonstrate a proactive or positive safety culture underpinned by openness and honesty. Systems to ensure learning from incidents were ineffective, and opportunities to identify risks and embed good practice were missed.

The provider did not work effectively with people who used the service or with healthcare partners to establish and maintain safe systems of care. Systems and processes to share information with staff and external agencies were not always effective in supporting the delivery of safe care and treatment. Arrangements for shared care when patients moved between services were not always well coordinated. We found that the system to manage workflow and tasks did not ensure that patients’ needs were always met. For example, we found a number of blood test results which were not actioned in a timely way.

Staff were not always sufficiently aware of local services and support networks to ensure appropriate referrals were made to meet patients’ needs or prevent ill health. Reception staff had not fully received or effectively applied care navigation training to ensure patients were directed to the most appropriate services and most appointments were based on a “first come, first served basis.”

Multi-disciplinary meetings were not effective in identifying and managing the needs of patients with complex conditions or those approaching the end of life. Clinicians did not always follow established care and treatment pathways when treating or referring patients to other services. Referrals to secondary or specialist care were not always made promptly, and follow-up for patients referred under the two-week wait pathway for suspected cancer was not assured because there was no effective process in place to monitor these referrals. Systems for processing correspondence from secondary care, including discharge letters and summaries, were not always timely or effective and we saw letters with action required that had not been completed.

The service did not demonstrate that people were safeguarded from the risk of abuse. While there was some evidence of working with partner agencies, this was not always effective. Systems and processes to respond to suspected abuse or neglect were not robust or correctly applied.

Safeguarding training for clinicians was not assured at a level appropriate to staff roles and responsibilities because checks were not completed, specifically for locum staff. Not all staff demonstrated a clear understanding of safeguarding procedures, including awareness of the designated safeguarding lead or the appropriate actions to take if concerns arose. Staff confidence in reporting concerns was variable.

Systems to flag safeguarding concerns within patient records were not used effectively to ensure all relevant staff were aware of risks. We received feedback and reviewed clinical records where safeguarding concerns had been raised with the provider but had not been followed up. Safeguarding of people using the service could not be assured through the provider’s systems.

Recruitment procedures were not successfully followed or documented to ensure staff suitability and provide assurance that staff had the relevant experience or qualifications to provide safe and effective care.

The service took some steps to work with people to understand and manage risks in a holistic way. Initial assessments included recording physical, psychological, and personal circumstances, and some care plans were in place. Information was available online to support people in understanding long-term conditions and how to manage them.

We identified significant concerns regarding the management of risks to ensure a safe environment for both patients and staff. A health and safety assessment carried out by an external company on 6 June 2023 found that the standard of health and safety management was below an acceptable level. The report highlighted several areas requiring urgent attention and included an action plan. Although we were informed that some improvements had been made, there was no clear system in place to demonstrate that all outstanding actions had been completed.

For example, the report required the urgent arrangement of a Gas Safe registered engineer to carry out maintenance and inspection of equipment and to issue a gas safety certificate. This had not been completed at the time of our assessment. It was also recommended that the external fire escape staircase undergo a formal inspection by a structural engineer within 6 weeks; this had not taken place.

We also noted environmental and security concerns. The patient toilet was located between the front entrance and the reception area, making it accessible directly from the street without staff awareness, which compromised security. There was no emergency alarm in place for patient use in the case of any need for help. The ground floor staff toilet was in a poor state of repair and did not have a lock on the door, compromising privacy and security.

In addition, extension leads were in use throughout most rooms without evidence of risk assessment. Some were suspended from plug sockets adjacent to clinical couches, posing a potential hazard to patients undergoing examination.

The provider did not ensure there were enough qualified, skilled and experienced staff supported by effective supervision, learning opportunities and development. There was limited protected learning time, and few structured meetings where key topics such as incidents, safety alerts, safeguarding, complaints and improvement actions were routinely discussed with all staff.

Most non-clinical staff had completed training appropriate to their role, but this was not the case for all clinical staff. Appraisals were not up to date for all staff and supervision, particularly for clinical staff, was reactive and undocumented.

Staff told us they did not always feel there were enough to deliver safe, high-quality care, although they felt they generally worked effectively as a team. Arrangements for covering sickness, absence and vacancies were in place, but staff told us it did not always feel like a fair process. There was very high use of locum clinical staff.

Recruitment processes were not carried out in line with requirements. Insufficient information was available for locum staff. A standardised recruitment checklist had been introduced to improve consistency; however, this was not yet fully embedded.

Infection prevention and control was not managed in a way that ensured the environment was always clean and free from possible risks of infection. We found that clinical waste was stored in an unsecured, unlocked bin in the backyard which was accessible to members of the public and could contain materials that could be infectious or toxic. We found mops stored in a way that could lead to the spread of bacteria. We found several areas, including clinical rooms, with a build-up of dust. This issue had not been identified in an audit undertaken on 20 January 2026. There were holes to the surface of 1 of the examination couches which had not been identified in the audit. However, this issue along with several others had been identified in an ICB audit dated 6 February 2026. No action had been taken about this and some other concerns at the time of the assessment and there was no action plan with proposals to rectify these concerns.

Medicines management and safety alerts were not handled in a way that ensured patient safety. As part of our assessment, we conducted a series of remote clinical searches of patient records. The practice did not effectively manage patients prescribed a high-risk medicine (Lithium). Clinical searches identified 4 patients who were issued Lithium prescriptions without appropriate blood monitoring, placing patients at risk. Additionally, out of 5 patients reviewed, 2 patients continued to receive a thyroid medicine (Levothyroxine) prescription without up-to-date blood test results . Without appropriate monitoring, the prescribed doses may have been unsuitable, increasing the risk of unsafe prescribing.
Further concerns were identified where 2 patients out of 5 reviewed, were prescribed medicines without receiving appropriate advice regarding potential impacts on blood pressure, and without any evidence of blood pressure monitoring. This placed those patients at risk of potential harm.