Killamarsh 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 remains the same.

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.

A representative from the Patient Participation Group (PPG) told us the provider took concerns seriously and proactively made improvements to the service. For example, a new telephone system to improve access to appointments. Managers encouraged staff to raise concerns when things went wrong. During staff meetings, the team discussed and learnt from clinical issues. Staff told us there was an open and transparent culture, and that safety was a priority. The provider had processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Learning from incidents and complaints resulted in changes that improved care for others.

There were systems in place to monitor trends in significant events and complaints and action was taken to address them. A trend in complaints relating to people’s dissatisfaction with the attitude of a member of staff had been identified and appropriate action and training had been put in place to address it.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

There were systems in place for processing information relating to new patients and summarising of records. The service worked with other providers to deliver shared care and when people moved between services. Referrals and test results were managed in a timely way.

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. They shared concerns quickly and appropriately.

Safeguarding policies were in place however they lacked detail. For example, types of abuse such as modern slavery and human trafficking; actions to take when vulnerable people or children failed to attend primary or secondary care appointments: actions to take with frequent attenders to AE. Safeguarding meetings were in place and peoples’ records were updated. Whilst there were dedicated meetings in place to review the care of different groups of vulnerable adults, a comprehensive list of vulnerable adults was not in place. The provider added this to their risk register with a completion date of 31 October 2025.

To mitigate potential risks to vulnerable people, the service maintained a list and alert system called Kid Gloves to identify vulnerable people who needed to be seen on the day if they contacted the practice. For example, people at risk of self-harm or people near the end of their lives. This list was reviewed monthly to ensure it was current and up to date.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Emergency equipment was available and maintained.

The service made sure equipment, facilities and technology supported the delivery of safe care. There was a business continuity plan in place which was monitored and reviewed. An in-house fire risk assessment had been completed and lead staff had been identified as fire wardens. A recent fire drill had been carried out and an action plan had been put in place to address any issues identified. Control of Substances Hazardous to Health (COSHH) risk assessments were in place.

However, potential risks were not always fully mitigated because some risk assessments had not been completed. A health and safety risk assessment for the building had not been completed. Following our assessment the provider forwarded this to us. Some blind hoops were not secured to walls in line with national safety alerts. Following our assessment the provider sent us photographic evidence this had been addressed. Regular testing of the water for legionella was in place however, a legionella risk assessment had not been completed. Following our assessment the provider sent us evidence that the risk assessment had been booked with an appropriate provider for 14 November 2025.

The service made sure there were enough qualified, skilled and experienced staff who received effective support, appraisals and development. Staff told us they were always supported to attend additional training specific to their role which enabled them to work together well to provide safe care that met people’s individual needs. Safe recruitment practices were followed however, a system for checking professional registrations were up to date was not in place. Following our assessment the provider set up annual reminder alerts 12 weeks before professional registrations expired to monitor they were appropriately updated.

The provider’s mandatory training matrix did not identify all of the appropriate training needs of staff to support them to carry out their roles effectively. For example, sepsis awareness, information governance, health and safety, equality and diversity and manual handling. Designated fire wardens had not completed appropriate training to carry out this role. Following our assessment, the provider reviewed their training matrix and forwarded an updated copy to us. This included planned completion dates for each member of staff. Training records for a recently recruited salaried GP were not available on the day of our assessment. Following our assessment the provider forwarded them to us.

Non-medical prescribers gave us examples of when they had received feedback on their prescribing however, this was ad hoc and not formalised. Following our assessment the provider sent us details of their revised systems for formalising this process and supported this with an updated policy. There was an implementation date of 6 October 2025.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. Systems for ensuring staff immunisations to potential healthcare acquired infections were up to date was in place.

There was a designated infection, prevention and control (IPC) lead and staff had received relevant training. Cleaning schedules were in place and there was evidence they had been followed. The practice was visible clean on the day of our assessment. The annual IPC audit had recently been completed and an action plan was partially completed. The audit and action plan identified the need to deep clean carpets in the waiting room. The provider informed us initially they had purchased a carpet cleaner but this was unsatisfactory so had arranged for a professional cleaner to carry out this work. However, they were unable to provide evidence of this. Following our assessment, they put a rolling carpet cleaning schedule in place to mitigate potential risks.

The service mostly 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.

Staff involved people in reviews of their medicines and helped them to understand how to manage their medicines safely. People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms.

Staff received regular training and felt confident managing the storage, administration and recording of medicines. Staff followed protocols to ensure they prescribed all medicines safely. Recall systems were in place to ensure people received all recommended medicines reviews and monitoring. However, their systems for managing persistent non-compliance with recalls were not clearly recorded in the practice’s medicine policies. Medicines were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines.

Waste medicines were disposed of appropriately. Staff stored medical gases, such as oxygen, safely and an oxygen handling and storage protocol was in place.

A system was in place to track prescription stationery throughout the practice however, records did not always tally. Following our assessment, the provider sent us evidence that a risk assessment had been completed to mitigate this occurring again.

The provider had systems to manage and respond to safety alerts and medicine recalls. Staff followed established processes to ensure people prescribed medicines with specific risks received the recommended monitoring and advise. For example, people prescribed a medicine used in the treatment of diabetes were made aware of potential risks although this was not always coded in their records. The provider had audited this group of people and an action plan with a completion date was put in place.

In response to our findings, the provider carried out an audit of women of childbearing age who were prescribed a medicine that could cause birth defects in the developing foetus. The audit identified 6 out of 11 people prescribed this medicine required a pregnancy prevention plan to be put in place. A completion date of 31 October 2025 was put in place to achieve this.

Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. Prescribing data reviewed as part of our assessment confirmed this. For example, the prescribing of broad-spectrum antibiotics was lower than the national average and this was consistent over time. Prescribing of other types of antibiotics was in line with the national averages.