Naseby 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 assessed all quality statements in this key question. At our last inspection, we rated this key question as inadequate. At this assessment, the rating remains the same.

We did not find evidence that the provider had identified and learned lessons from our previous inspection and the resulting suspension. Whilst the provider had introduced some systems and processes, they were not able to demonstrate that the practice had adopted a system that would ensure all information was accessible to the staff who needed it. The provider had taken some action to address risks within the clinical environment but significant gaps in risk management remained. Potential new staff had been identified and recruitment had begun. However, the provider had not established how safe service provision would be assured in the event the suspension was lifted and new staff had not yet been fully inducted. The provider had not worked with the caretaker provider to understand what staff training had been completed during the suspension period. We were not assured that the processes and policies proposed by the provider would ensure that medicines were managed safely.

The service was in continued breach of legal regulation in relation to safe care and treatment and good governance.
 

This service scored 34 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had produced significant event analysis documents to address the issues raised by us during our previous inspection. However, there was no clear analysis of the root cause of the issues or reflection on how the situations could have been prevented. During this inspection, evidence that the provider had reflected on the quality of service they had provided or the impact this had on the health of their patients was limited. We engaged with the provider during the suspension period to seek assurance regarding compliance and the management of identified risks. The provider did not demonstrate a proactive or systematic approach to engaging with relevant stakeholders in order to ensure the safe delivery of services. They relied on unverified assumptions rather than seeking accurate information and did not take timely action to clarify uncertainties that were affecting progress. This limited their ability to plan and implement the improvements required to ensure patient safety.

The provider had designed new pathways for the management of patients with long-term conditions such as diabetes however, they were unable to clearly explain how the systems would operate in practice or identify staff responsibility at each stage of the process. It was unclear whether their systems and processes had been aligned with those of the caretaker provider which existing administrative staff had been trained to use. There was no evidence that the provider had considered these existing arrangements or planned how or when staff would be retrained to implement the new pathways.

During our previous inspection we identified that the safeguarding registers were held on the desktop of the safeguarding lead’s computer and were not accessible to all senior staff who needed to access them as part of their role. Updated policies and procedures regarding safeguarding of adults and children had been produced by the provider for this assessment. However, there was no evidence to show they had considered adopting a suitable system which would allow them to store such information securely whilst making it easily accessible to relevant staff.

During our previous inspection we found the practice did not always work well with people to understand and manage risks. Clinical and environmental risks were not always identified, assessed and mitigated to keep people safe. For example, we found large numbers of patients who had possible missed diagnoses which had not been identified. This was because patients’ records were not coded with a diagnosis to ensure they were called for regular monitoring and reviews. This meant the patients were not given the opportunity to manage the health risks associated with their condition adequately. At this inspection new pathways had been created to ensure that patients with possible missed diagnoses were identified. However, we were not assured that these were fully effective or would be adequately resourced as the provider had not used up to date data to quantify the projected number of patients who may require recall and review in the future. This was necessary to ensure there was sufficient appointment and staffing capacity to accommodate those reviews in a timely way.

During our previous inspection, the provider was undertaking building work to expand the practice facilities. During the period of the suspension the building work was paused and safely closed down to minimise the risk to patients and the caretaker provider’s staff. As part of this inspection the provider submitted evidence to demonstrate that the building work would be restarted and completed to increase the number of clinical rooms available for use, improving capacity.Initially no evidence was provided to show that the potential risks this posed to patients and staff had been assessed and mitigated. Following this assessment the provider submitted a risk assessment that had been completed by the building contractor.

During our previous inspection we found the management of fire safety was ineffective. There were 2 fire risk assessments running concurrently but neither adequately identified the fire hazards within the practice nor listed any mitigating actions to reduce potential risks. Records to evidence that regular fire alarms, smoke detection and emergency lighting testing were not clear and did not provide a specific audit trail to confirm what had been checked. The Care of Substances Hazardous to Health (COSHH) and Health and Safety risk assessments were incomplete. There was no water safety risk assessment or associated record keeping. When we asked the practice management team about this, we found they had a lack of understanding about risk assessments and fire safety.

At this inspection, the provider submitted new documents to evidence that fire safety systems had been serviced and tested; however, they applied only to newly installed parts of the system and it was not clear that the entire system had been checked. Evidence was submitted that showed an independent fire risk assessment was completed on 22 January 2026. However, the caretaker provider arranged this and there was no assurance that the provider had taken proactive action to rectify the concerns we expressed. We were not assured that fire safety was a priority or that subsequent fire risk assessments would be comprehensive and timely.

A COSHH risk assessment was supplied for this inspection however, it was incomplete as it did not include all potentially hazardous substances used in the practice. This risk assessment was very similar to the one submitted as part of the previous inspection and suggests that no lessons have been learned from CQC’s concerns regarding what a comprehensive COSHH risk assessment should contain. No new COSHH policy was provided.

At this inspection we found that the health and safety risk assessment only covered physical security in the building and no other aspects of health and safety. There was no risk grading or scoring used and there was no supporting Health and Safety policy. We were not assured that health and safety risks for staff and patients have been identified, graded and mitigations put in place to protect people’s safety.

As part of this inspection a ‘Legionella disinfection certificate’ was supplied; however, no supporting legionella risk assessment, flushing logs or temperature monitoring records were supplied. A legionella policy was submitted, which identified the responsible person for water safety, but no evidence was provided of relevant training or competency assessment for that person. Although the policy referred to formal risk assessments being arranged, no reports from such assessments were supplied. As a result, we were not assured that the water system has been adequately assessed, risks had been mitigated, or appropriate ongoing monitoring was in place.

We were not assured that the provider had taken sufficient action to demonstrate that all safety aspects of the care environment had been fully risk assessed, checked and serviced and that people would be protected from the risk of harm should they resume delivering regulated activities.

At our previous inspection, the leadership team explained that numerous clinical concerns, including inaccurate foot checks for patients with diabetes and incomplete or non-contemporaneous record keeping were due to excessive workloads and insufficient staff capacity.

During this assessment, the provider produced plans to increase non-medical clinical staffing and had identified suitable candidates for these roles. However, the provider had not carried out any analysis of demand (for example by using existing data for the previous 6 months as to the number of appointments required) or the additional capacity (number, type and hours of staff) required to meet that demand. The provider told us they were planning to use the same staffing numbers as the caretaker provider had instituted. However, the evidence they provided to explain how much additional staffing they planned to recruit and how the staffing rosters would be designed were unclear and did not reflect the caretaker provider’s current level of resource. Some of the proposed staff did not have appropriate skills or experience and potential workloads for some new staff were excessive.

Following our inspection, the provider recruited an independent consultancy service to carry out a demand / capacity analysis and to help them recruit appropriate staff. This resulted in an improvement in the planned structure for staff rosters and candidates with more appropriate skills and experience and realistic job plans. However, the provider had no plans in place to cover any notice periods new staff would need to work or the period of induction and training they would require before commencing in post. The provider told us that new staff had been recruited on ‘locum-type’ contracts for 3 months but did not clearly explain whether they would become permanent staff after this 3-month period. This lack of clarity created uncertainty about future workforce stability and limited assurance that safe staffing levels could be sustained.

At our previous inspection we also raised concerns regarding the competence of staff in leadership roles, both clinical and non-clinical. At this inspection, the provider was able to show that the relevant staff had completed some limited training which was specific to the issues we had identified. However, they had not carried out any competency assessments, training needs analysis or identified any learning requirements in order to put a personal development plan in place for staff. Following this inspection the provider did complete an analysis and put in place clinical supervision for the affected staff members. However, not all areas identified in the learning needs analyses were included in the training evidence. The scope of the job role for some of these staff had also been drastically reduced to effectively eliminate any independent clinical decision-making and limit managerial decision-making rather than ensuring the staff had the required level of skill and competence. This created a risk that the service would continue to lack sufficient clinical capability to deliver safe and effective care. We were not assured that there was a clear plan in place to build a competent, cohesive practice management team.
 

At our previous inspection no infection, prevention and control (IPC) risk assessment was in place, hand gel was not available throughout the practice and the hot water supply was not reaching the required temperature to ensure it was safe. We identified several areas of the practice that were visibly dirty and clinical products were being stored in an outdoor cupboard that was not secure, sanitary or weatherproof. A legionella risk assessment had not been completed and the provider could not evidence that water temperatures were being regularly checked and recorded.

At this inspection, the provider did not produce an up-to-date IPC risk assessment but did supply a new cleaning schedule and a certificate which demonstrated that the water system at the practice had been disinfected and no legionella had been found. Following the assessment the provider shared a copy of the latest IPC risk assessment completed by the caretaker provider on 15 September 2025. The risk assessment was divided into modules, depending on the areas assessed. Five modules scored less than 95% and required remedial actions. At the time of the risk assessment the caretaker provider had been in place for less than 6 weeks and the majority of areas for improvement related to the period prior to the suspension of the providers. For example, hand wash dispensers stored on the sink instead of being wall-mounted. The provider did not provide a legionella risk assessment. Legionella is a bacterium that can proliferate in stagnant water and can cause disease in humans. A legionella risk assessment is important to ensure that the water system in a building does not have dead ends or other areas where water can stagnate and to ensure that both hot and cold water meet the safe recommended temperatures. Based on this risk assessment a suitable regime of regular testing of water temperatures and flushing of little used outlets can be carried out to maintain water safety. The provider could not evidence that they regularly checked water temperatures or flushed required outlets.

Taking account of all the evidence, we were not assured that the provider had a safe and robust approach to preventing and controlling infection risks.
 

At our previous inspection we found that medicines were not being managed safely. Medication reviews were not being completed effectively. Medicines records were not accurate or kept up to date and medicines that had been started by hospital consultants were not added to patient records. Correspondence relating to changes in patient medicines was not being actioned in a timely manner.

At this inspection, although the provider had updated their systems and processes, we did not receive assurances that there were coherent, embedded and effective processes in place to ensure medicines would be prescribed and managed safely.

The provider shared their plans to recruit 2 new pharmacists to undertake medication reviews, however 1 of the proposed candidates did not have the skills or experience to perform this role. Due to a lack of clinical rooms (due to current building work) the provider proposed a fully remote pharmacy service utilising telephone and video appointments. There was no capacity for pharmacists to arrange face to face appointments should they need to assess a patient in-person.

Following this inspection the provider did submit improved plans regarding the number of pharmacists they planned to recruit and they proposed alternative candidates with the requisite skills. The proposed job plan had been streamlined so that there would be improved capacity to accommodate long-term condition reviews, high-risk drug monitoring and medicine reviews. The provider also sourced some additional clinical room capacity at a surgery half a mile away which could be used by pharmacists if required.

However, we remained unassured that there were clear, robust systems in place to ensure that patients received regular effective medicine reviews, timely high-risk drug monitoring tests and regular long-term condition reviews. Existing and new staff had not been trained in the new processes; plans were not in place to cover work whilst new staff were inducted and trained and it was unclear if new staff would become permanent members of the team. This created a significant risk of delayed or incomplete clinical monitoring resulting in patients not receiving ongoing and proactive management.