Guidepost Medical Group

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 62 (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.
The service operated an open and transparent significant event process, with staff encouraged to bring forward incidents for discussion. Events could be anonymised to maintain a focus on learning while reducing barriers to open and honest reflection. This supported a strong culture of learning across the team. Discussions focused not only on individual cases but also on how learning could be applied to wider practice systems, ensuring that improvements were maximised and embedded to reduce the risk of recurrence. For example, there was an incident where a required follow-up action was not completed due to a workflow issue. Following a review, changes were made to the process, and additional checks were introduced to reduce the risk of recurrence and improve patient safety.

The service collaborated effectively with patients and healthcare partners to establish and maintain safe systems of care, where safety was actively managed and monitored. They ensured continuity of care, particularly when patients transitioned between different services. This was achieved using a ‘usual GP’ model, which promoted consistency, familiarity, and ultimately enhanced patient safety.
Systems were in place for processing information relating to new patients, supporting safe and efficient onboarding. The service worked in partnership with other providers to deliver coordinated shared care and to facilitate smooth transitions for patients moving between services. Referrals and test results were managed promptly and efficiently, reducing risks and enabling timely, informed clinical decision-making.

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.
The service worked with patients and healthcare partners to understand and promote safety, ensuring individuals were protected from harm, abuse, and discrimination while improving their overall wellbeing. Safeguarding arrangements were robust, with a dedicated lead, clear policies, and staff appropriately trained.
Regular multidisciplinary meetings supported effective information sharing and coordinated care. A register of vulnerable patients was maintained, with each allocated a usual GP to promote continuity. Safeguarding cases were clearly coded, and additional measures such as protected addresses for patients experiencing domestic abuse were in place. The practice worked collaboratively with external organisations and responded to concerns promptly and appropriately.

When we carried out remote clinical searches, we identified some concerns in the management of long‑term conditions, including some overdue reviews. However, we also found that the service generally worked with people to understand and manage risks in a holistic way. Care provided was mostly safe and supportive, enabling people to do the things that mattered to them.
Emergency equipment was available and appropriately maintained. Staff were able to recognise deteriorating patients and understood the actions required. Patients were also advised on risks related to their conditions and the appropriate steps to take if their condition deteriorated.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.
Arrangements were in place with the building owners to ensure the premises complied with relevant regulations. We saw evidence of health and safety risk assessments being carried out. Cleaning arrangements were also established, and during the assessment, the premises were observed to be clean and tidy. A business continuity plan was in place, outlining how the service would maintain operations during emergencies or disruptions. This plan was routinely monitored and regularly updated to ensure it remained current and effective.

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.
There were a range of clinical and non-clinical roles within the practice. 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. Safe recruitment practices were followed.

The service effectively assessed and managed the risk of infection. A designated Infection Prevention and Control (IPC) lead was in place, and staff had received appropriate training. Systems were established to identify and control infection risks, with concerns shared promptly with relevant agencies. Cleaning arrangements were in place and followed consistently. Regular risk assessments and audits were undertaken, with appropriate actions implemented to mitigate identified risks.

The service did not have effective systems in place to ensure all medicines were managed safely. This meant the service was not consistently assessing, monitoring and mitigating risks to patients and providing safe care and treatment.
Clinical searches and record reviews identified some gaps in the monitoring and oversight of several high-risk and long-term conditions, including asthma, chronic kidney disease (CKD), hypothyroidism and diabetes, as well as patients prescribed medicines such as direct oral anticoagulants (DOACs), non-steroidal anti-inflammatory drugs (NSAIDs), antiplatelet medicines, and clopidogrel with proton pump inhibitors (PPIs). Concerns included some inconsistent monitoring, some incomplete or delayed reviews, some inappropriate prescribing, some poor documentation, and a lack of follow-up at times, which increased the risks to these patients. In particular, some patients with asthma showed indicators of poor control without appropriate review, and some medication safety risks such as drug interactions and dosing decisions were not always identified or managed effectively. The provider told us they already knew that work needed to be done on calculating Creatinine Clearance levels for patients at risk of CKD and this was already planned with the support of the PCN Pharmacist.
During the assessment, some medicines and clinical consumables were found to be out of date, including adrenaline (epinephrine) in a home visiting kit, Pneumovax vaccines in the vaccination fridge, and items such as gauze dressings and syringes. While the majority of medicines and supplies were in date, the practice took immediate action to remove and dispose of out-of-date stock. Out-of-date blood glucose monitoring devices were also identified; staff confirmed these were sample items not intended for patient use and they were promptly removed. These findings indicated some gaps in the providers’ stock monitoring processes, although risks were mitigated at the time of inspection through swift action taken by the provider.
Staff managed prescription stationery appropriately and securely. Medicines were stored safely and maintained at appropriate temperatures. Processes were in place to support regular checks of these; however, these had not been fully effective in identifying and addressing all risks.