Potterells Medical Centre

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• 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

At our last assessment, we rated this key question as good. At this assessment, the rating has changed to requires improvement.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We looked for evidence that people were protected from abuse and avoidable harm.

The service had a proactive learning culture where safety was prioritised. Staff were encouraged to raise concerns and there were systems in place to report incidents, near misses and safety events and we saw evidence that lessons were learnt; however, there were gaps in these systems.

There was an incident policy in place; however, this lacked clear examples of what constituted a significant event and reference to notifiable incidents to CQC and the duty of candour. Clinical staff we spoke to were aware of the duty of candour and told us they were committed to meeting these requirements and to informing patients of incidents, even where no harm had occurred. For example, where minor errors occurred, including those that did not result in patient harm, patients were informed in line with their duty of candour.

We saw evidence of an open culture and how significant events were analysed, reviewed and improvements made to prevent recurrence, which included 2-week wait (2WW) cancer referrals, administrative errors, clinical coding improvements and a flooding incident at the main site. Staff described examples of learning from incidents. We reviewed an incident involving a patient at the university branch site, which identified a potential risk to staff safety where a patient became distressed or aggressive. The incident was managed appropriately and subsequent review identified learning about staff safety arrangements. The practice identified that panic buttons were not available across both sites and took action to address this. Panic buttons were subsequently installed at both sites to support staff safety.

Leaders told us all staff were invited to meetings; however, attendance was variable. Staff based at the university site were able to join via Microsoft Teams, and meeting minutes were stored on a shared drive. Staff reported that learning from incidents was discussed in meetings and shared with those present. While evidence of learning and action was seen, staff feedback indicated that learning was not consistently shared across all staff groups, particularly amongst administrative staff. Clinical staff reported a more consistent involvement, including being invited to meetings where significant events and learning were discussed.

We saw evidence of dedicated monthly significant event meetings that analysed 16 significant events over 6 months since January 2025. However, these meetings did not include attendee names and there was limited evidence as to how the learning was cascaded to non-attendees. Although some learning event audits had been completed, they were not always recorded using the practice’s designated template, limiting consistency and completeness of analysis.

The significant event register submitted by the practice dated from January to September 2025 recorded 19 incidents. The register was brief and did not consistently capture sufficient detail; for example, 2 entries from the register were recorded as outstanding and 2 others had no outcomes recorded next to them. We were also not assured that all incidents were being recorded as the partners’ meeting minutes from January 2025 recorded that incorrect smear bookings had occurred at the university site due to staff error; however, these incidents were not recorded as a significant event. A complaint response from July 18, 2025, from the practice manager to a patient referred to a catastrophic system failure that affected the practice phone system; however, this was also not recorded in the significant events log. There is a risk that incomplete and inconsistent significant event recording limits effective oversight, reduces the reliability of governance systems, and prevents identification of trends.

Overall, there was evidence of a positive learning culture and responsive incident management; however, weaknesses in the consistency, completeness and oversight of significant event systems, along with inconsistent sharing of learning across all staff groups, reduced assurance that all risks were being identified, recorded and embedded into practice.

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 new patient information, including the use of an offsite provider to store patient records. A dedicated summariser was based at the university site, where the notes vault was also located due to single-site storage arrangements. Students from overseas who did not arrive with their full medical records, were identified and set aside for a GP review to ensure appropriate clinical oversight.

The service worked with other providers to deliver shared care and when patients moved between services. Referrals and test results were managed in a timely way and we saw evidence of oversight. Pathology results were reviewed daily by GPs, supported by a buddy system. Significantly abnormal results were escalated promptly to the duty GP. The second lead GP with oversight over pharmacy prescribing was based at the main site; however, a GP based at the university site would monitor prescribing requests which were brought to the university site by hand.System safeguards ensured results were not visible to patients until they were reviewed and filed. The practice operated a weekly phlebotomy clinic, generating high volumes of results; for example, diabetic monitoring with at least over 100 blood tests carried out for this patient group.

We found generally efficient processing of test results and documents with limited backlog.

The practice had arrangements in place for reviewing hospital discharge information. Discharge correspondence was reviewed by the GP who had made the referral to support continuity of care. The pharmacy team carried out post-discharge medicines reviews with patients and escalated any concerns to the duty GP. Administrative staff identified and escalated urgent actions from incoming correspondence, including safeguarding concerns and reports from ambulance and urgent care services. The practice told us that urgent actions were reviewed and completed within 24 hours of receipt. Letters requiring medicines reconciliation were also shared with the prescribing team.

The practice demonstrated a proactive approach for higher-risk groups. Patients discharged to the care home were reviewed within a week. For the wider population, there was a risk of delays in reviewing discharge information and coordinating ongoing care; however, no related incidents were identified on assessment.

We received predominantly positive patient feedback on referral management. Patients described referrals as swift and efficient, particularly for 2-week wait cancer care pathways. Examples included timely access to physiotherapy with effective one-to-one sessions and referrals to local gym services. Where delays occurred due to human error; the practice acknowledged this through incident analysis and implemented improvements to prevent recurrence.

The practice had a system in place for the management of referrals, including 2 week wait cancer referrals along with a safety-netting policy for urgent referrals; however, monitoring was required to ensure the 2 week wait log contained all the relevant information including the name of speciality and confirmation of appointment.

There were also safe systems and pathways in place for care home residents, with designated care home clinicians undertaking comprehensive medication reviews, including medicines reconciliation, arranging and monitoring blood tests, and actioning hospital correspondence to support safe and coordinated care. Feedback from the care home reported a straightforward and efficient registration process and clinical staff demonstrated good knowledge of their residents' medical histories and health needs.

The practice had safeguarding procedures in place; however, monitoring was required to ensure they were effectively applied across all areas. Staff received safeguarding training relevant to their roles; however, there were gaps in the training records provided, dating back to 2021 and 2022 for some staff.A safeguarding handbook, policies and named leads were in place and known to staff. Staff described an open culture where concerns were shared promptly and safeguarding responsibilities were mostly understood by staff.

The practice worked with external partners, including health visiting teams, community services and university wellbeing teams, to identify and respond to safeguarding concerns. Students were supported to register with the practice where needed and could be referred to wellbeing or specialist services. Monthly safeguarding meetings were held with clinical staff and managers alongside health visiting and community nursing teams to review cases involving children, families and vulnerable adults, including domestic abuse, postnatal mental health and complex household concerns. We saw evidence of these discussions during the assessment, with the safeguarding liaison health visitor contributing relevant concerns relating to children and families.

Staff described using interpretation services, where language barriers were identified in safeguarding cases such as domestic abuse. The lead GP provided a positive example of safeguarding practice where, due to identified risk, they appropriately overrode a patient’s request not to escalate concerns. The patient was subsequently reviewed through a home visit and found to be safe. The GP also demonstrated awareness of cultural needs when managing the case, supporting effective communication and engagement, as well as proactive risk management.

At the university site, mental health concerns made up a significant proportion of the health care needs. Staff described frequent safeguarding concerns at the university site, with occupational health and university teams escalating students presenting with mental health concerns, including suicidal ideation. In urgent, high‑risk cases, patients were prioritised appropriately, with triage bypassed and urgent GP appointments arranged. Unregistered students were supported to register to enable follow‑up. Students could also be referred to the university wellbeing service, which maintained its own register and could escalate directly to safeguarding or specialist mental health services where required.

Urgent safeguarding concerns were escalated appropriately outside of scheduled meetings in line with policy, supporting prompt access to care and timely risk management. We saw evidence of appropriate safeguarding action, including reviews involving multiple households and referrals to crisis services for students expressing suicidal ideation. A serious incident also occurred and from the evidence provided, the practice had carried out appropriate follow up and investigation.

GPs also described reviewing paediatric non‑attendances and contacting families where required. At the university site, reviews of those who did not attend appointments were carried out for all patients, with particular focus on those with mental health conditions to ensure their safety. Staff used clinical systems appropriately to protect patients, including restricting visibility of safeguarding records where there was a risk to the patient.

However, there were gaps in the governance and oversight of safeguarding systems; for example, the practice maintained child and adult safeguarding registers; however, only a partial log was provided and some entries lacked key information such as date of inclusion, status and completed actions. Although staff reported 33 children and 31 adults on the safeguarding register, another register reviewed was incomplete, limiting assurance that all at risk patients had been identified.

Systems were in place to support students with mental health needs; however, these were not fully aligned with safeguarding systems. The practice maintained a student at risk list and the university wellbeing team held a separate register but there was no clear safeguarding at‑risk student register held by the practice. Staff described that where safeguarding cases were too numerous to be discussed in meetings, patients were added to a waiting list on their clinical system for subsequent review. The pratice told us that due to their large student population; there was a lower proportion of individuals on the safeguarding register. However, these arrangements did not provide clear assurance that students identified as potentially at risk were consistently recorded and reviewed through the practice’s safeguarding processes.

Meeting records, including university at‑risk discussions, did not consistently record attendees, or how information and learning were shared with the relevant staff and while staff said they would escalate concerns, reporting pathways were not consistently understood. One university‑based manager told us they were not routinely involved in reviewing safeguarding registers, as this was the responsibility of the lead safeguarding GPs. However, 1 staff member reported they would escalate concerns to this same manager, despite them not being the safeguarding lead, indicating a lack of clarity in safeguarding reporting pathways and appropriate oversight. Other staff demonstrated awareness of the correct reporting pathways.

Separate arrangements were in place through university at risk meetings to discuss students with significant mental health concerns. The practice clarified that these were not safeguarding meetings and were intended to support information sharing between relevant services involved in supporting those students.

Staff described that coding for safeguarding was a work in progress, although the lead GP for safeguarding actively encouraged staff to record concerns using appropriate coding. The practice reported a low number of safeguarding cases originating directly from the service, with most concerns identified through external agencies, including police reports and domestic incidents, which were then coded onto the system.

While there was clear evidence of responsive care and effective multi‑agency working, weaknesses in governance in relation to documentation, clarity of some roles and integration of safeguarding systems reduced assurance that all safeguarding risks, particularly for vulnerable students, were consistently effective.

We looked at how the practice managed risk within the service and whilst we found adequate systems and processes in some areas, there were gaps in systems and processes in other areas.

Most staff could recognise a deteriorating patient and knew of action to take; for example, sepsis red-flag symptoms and the escalation process. For example, a GP was commended for responding promptly to an emergency at the university site, attending with equipment and stabilising an individual who was not registered with the practice, until paramedics arrived. Although we saw most staff were aware of red-flag symptoms and action to take, further action was required to ensure non-clinical staff were aware of red flag symptoms for sepsis. During the assessment, we spoke to a staff member who was unable to identify these symptoms and a review of training records confirmed they had not completed the sepsis training module. However, sepsis awareness posters were visible during the assessment.

People told us they knew what to do and who to contact if their condition did not improve or if they experienced unexpected symptoms. Patient feedback we reviewed supported this. We also saw further positive outcomes where patients with deteriorating conditions presented at the practice. For example, following a long-term condition review, a clinician arranged emergency hospital admission after identifying abnormal observations in a patient. In another case, a routine consultation identified red flag symptoms of cancer, enabling timely escalation.

We saw the practice had emergency equipment available across sites, including nebulisers, emergency medicines and a defibrillator at the main site. Equipment was appropriately stored, signposted and staff where it was located.

At the university branch site, a defibrillator was not held onsite but could be accessed by calling the university estates, with a reported response time of under 3 minutes. This was tested during the assessment and answered immediately. Oxygen was available at both the main site and university branch site. Emergency medicines were kept locked, which may delay timely access to treatment in an emergency and required further consideration. In addition, the medical emergencies policy did not include specific arrangements for the university site.

Emergency equipment at the main site was checked weekly; however, we identified gaps in documentation, including missing initials on several dates; for example, a week in January and in April 2025 when there were gaps in checks, which reduced assurance regarding consistent checks. Overall responsibility for emergency equipment sat with the resuscitation lead and nominated staff. From the 5 staff records we reviewed, we found 4 staff were trained in basic life support and a training date was in place for a new member of staff to attend their training.

The service endeavoured to detect and control potential health and safety risks in the care environment; however, monitoring was required to ensure this was consistently applied, as they did not make sure that equipment, facilities and technology always supported the delivery of safe care.

The practice maintained a risk register and contracts were in place to ensure the premises were maintained. The university branch location staff told us they were not responsible for the maintenance of the premises and the estates team dealt with the building maintenance, risk assessments and required actions. However, the practice should take steps to ensure the actions required for the part of the premises that they occupied were completed.

All staff were up to date with fire safety training; however, a fire safety policy was not provided. We found that a designated fire marshal was also in place at the university branch site. However, the practice should consider appointing a second fire marshal to ensure adequate cover during periods of absence.

An external fire risk assessment for the main site had been completed in April 2025. The practice had received the final report only a few weeks prior to this assessment. Some actions identified within the associated action plan remained outstanding, including the installation of fire seals on designated doors. The practice had also completed an internal, general fire risk assessment which formed part of its risk register.

Comprehensive fire drills were carried out twice a year at the main site, with evidence of a fire drill taking place in June 2025, although the practice manager advised the most recent drill had taken place in February 2025. Fire alarm testing was conducted weekly on random days at the main site and firefighting equipment, including fire alarm systems in the two portacabins, was serviced annually. Records showed that fire alarm and fire extinguisher servicing was due in November 2025.

At the university branch site, building security was managed by the estates team. Fire drills and weekly fire alarm testing were undertaken by the university. We saw records of a fire drill carried out in January 2025 by the university’s fire marshal. We were not provided with evidence of any further drills since this date; however, the practice told us that fire evacuations happened a lot at the university site because the students frequently set off the fire alarms. Staff were aware of the fire assembly points at this location.

The practice reported that electrical safety testing had recently been completed, with an ongoing improvement plan in place. This included ensuring the safety of portacabin electrics, purchasing surge protectors and replacing extension leads to maintain a safe clinical environment.

Portable appliance testing (PAT) and equipment calibration were completed in March 2025 across both the main location and university branch site, in line with required safety and maintenance standards. We observed in date PAT stickers on equipment. However, 3 items at the university site, including 1 blood pressure machine and 2 thermometers had failed calibration and there was no evidence of action taken to rectify this. At the main practice site, we observed an examination lamp in 1 clinical room without a PAT sticker and with exposed wiring, which did not appear to have been picked up during the earlier PAT test. In addition, we did not see evidence of PAT testing or calibration for equipment within the 2 portacabins. There were no PAT stickers observed on equipment such as scales and torches within these areas, indicating gaps in ensuring compliance with monitoring and maintenance of equipment safety. Following the inspection, the practice told us the highlighted items which failed PAT testing had been removed from circulation and safely disposed of. The practice also provided evidence to show all calibration and PAT testing had been successfully completed in the practice.

The arrangements for monitoring and managing legionella risks were in place. Evidence showed that hot water systems identified for replacement at the previous assessment had been changed. Legionella checks were also completed at the university healthcare site where they were carried out in August 2025.

We saw an in-house control of substances hazard to health (COSHH) risk assessment dated October 2025, which was reviewed annually. However, COSHH data sheets for products in use were not available, consistent with the findings of infection prevention and control audits carried out in March 2023 at both sites. The absence of these data sheets limited assurance that staff had access to information required for the safe handling, storage and disposal of hazardous substances. The practice told us the COSHH data sheets were held on its shared drive and were accessible to staff.

There was a health and safety policy; however, there were gaps in health and safety training records, with 3 staff members overdue, including 1 outstanding since 2020, and a further training requirement identified as imminently due.

The practice had completed an internal health and safety risk assessment in April 2025 for the main site which we were not provided with on assessment. They told us that this was undertaken by the practice manager with guidance from an external provider. The practice manager had previous health and safety experience and was suitably skilled to carry out the assessment; however, it was not clear how the provider assured themselves that health and safety arrangements remained consistently effective across all areas. Health and safety posters were displayed in the practice.

An annual health and safety return for the university site had last been completed by the practice in 2023, with no up-to-date version available at the time of assessment, which limited assurance that risks were being appropriately identified and managed.

We observed appropriately furnished waiting areas and clear walkways. However, visual checks identified insect traps in 1 clinical room at the main site. The traps were labelled to identify their purpose and were removed following feedback from the inspection team. Following the inspection, the practice provided an up-to-date COSHH data sheet for the product. We also observed unsecured blind loop cords in one of the portacabins. This was raised with the practice who completed a risk assessment and determined the risk to be low as the cord was positioned away from patient seating areas; however, they advised they would install a wall attachment to secure the cord after the inspection. Following the inspection, the practice provided evidence to show that cord attachments were now installed within the portacabins.

Various risk assessments had been undertaken, including those relating to manual handling, slips, trips and falls, lone working and wheelchair use. Risk assessments for locking and unlocking procedures were in place at both the main site and the university site and were due for review in September 2027.

At the university site, arrangements were in place for staff safety when closing the premises. The last member of staff leaving the site was required to contact security via telephone so that the building could be alarmed before departure. The building doors were set to lock automatically at 5pm and at 1pm during the summer period.

Premises and security arrangements were included in the internal practice risk register and security CCTV was installed at the main practice with remote access available. There was signage in place.

The practice had an established and recently updated business continuity plan. This was implemented effectively during a recent flood, enabling the practice to maintain service delivery. Telephone lines were diverted to the university site, allowing operations to resume without delay. However, we found 2 of the different staff we spoke to, including one senior staff member were unaware of this plan in place.

The service made sure there were enough qualified, skilled and experienced staff and this was consistent with staff feedback where they felt there was enough staff to provide safe, high-quality care, despite the increasing demand. They also felt recruitment was generally easy because of their reputation and trainees generally wanted to stay with the practice or return to work for them. We did, however, note some gaps in the recruitment checks of staff, required learning and the implementation of the appraisal system.

There was a range of clinical, non-clinical and multi-disciplinary roles within the practice, including those from the primary care network (PCN) and the provider ensured there were enough qualified, skilled and experienced staff, suggesting a good mix of skills across the workforce. The GP team consisted of long‑standing clinicians, several of whom had specialist expertise, including in hormone replacement therapy (HRT), Intrauterine Device (IUD) fittings, diabetes and asthma. The nursing team included nurse prescribers and the administrative team had worked at the practice for many years, demonstrating strong staff retention. The practice was in the process of recruiting to a vacant reception post. Staff were working within their agreed areas of competence.

The practice supported staff development and learning needs; for example, one of the lead GPs supported a nurse to complete a prescribing course and a non-clinical staff member was promoted to a leadership role, reflecting a commitment to upskilling the workforce. The practice had a structured approach to supervision for pharmacy staff, with regular GP oversight, protected weekly debriefs and additional support for less experienced staff. One pharmacist primarily managed diabetic patients under GP supervision, while another had their work closely reviewed to support development. The practice also supported a PCN care home pharmacist working across four practices, visiting care homes weekly. As an independent prescriber, their prescribing was overseen by the GP, and the Primary Care Network (PCN) practices shared responsibility for mentorship. We saw evidence of prescribing audits undertaken by the GP for the PCN pharmacist.

There were arrangements to deal with poor performance and we saw evidence of this. There were also arrangements to manage staff absence and we found low sickness levels and low usage of locum GPs. Staff told us that during busy periods, the practice engaged locum GPs to provide additional clinical support and they utilised their winter pressures funding to continue their access commitments. Staff sickness was communicated promptly through their internal messaging system and overtime was available for staff. Care co-ordinator staff who typically did not have cover for their roles told us the assistant practice manager had the knowledge to step in when cover was required. However, the practice told us cover was also provided by the reception manager and secretarial team.

There was a recruitment and induction policy in place. However, there were gaps in staffing arrangements. Although clinical staff files contained evidence of professional registrations, there were gaps within recruitment records. One GP did not have references on file and qualifications were missing for 2 clinicians. In addition, induction records and signed confidentiality agreements were not available for 3 clinical staff. Disclosure and Barring Service (DBS) checks were in place for staff; however, some long‑standing employees had not undergone a repeat DBS check since their initial appointment; for example, in 2015.

The practice adapted their total triage system to cover for staff sickness. They told us the system could be adjusted to respond to staff sickness and fluctuations in demand. During periods of increased pressure, such as busy periods and bank holidays, the practice reduced routine appointments to increase capacity for same-day access. This enabled the practice to prioritise urgent need and ensure patients were able to access appropriate care in a timely way.

While most staff received appropriate support and supervision, we found some inconsistencies in how appraisals were completed and documented. One member of staff had been in post for 4 years without a formal appraisal, despite having received a promotion and although informal discussions had taken place, no formal plan had been put in place. Appraisal responsibilities were shared between the reception manager at the main site and the university branch manager and records showed that of the 5 staff files we reviewed, 1 appraisal had not been carried out and another had not been signed. One staff member in post for 2 years had only received 1 appraisal and stated that they had not received a copy or appraisal feedback from the provider.

Most staff training was up to date; however, there were gaps in mandatory training for both clinical and non-clinical staff, including learning disability and autism, first aid, cyber security, privacy and dignity, health and safety, sepsis and paediatric basic life support. The practice held monthly protected learning afternoons, during which routine activity paused and external clinical cover was arranged. Two sessions each year were delivered across the PCN at an external venue, with the remainder held onsite.

The service had arrangements in place to assess and manage the risk of infection; however, the practice should ensure completed action plans were recorded on the audit documentation, as this was not always consistently recorded.

The practice manager told us that most staff had completed their infection prevention and control (IPC) training. However, training records showed that 7 staff members had not yet undertaken the required IPC training. The IPC lead for the practice continued to oversee infection control across both sites as staff rotated. There were plans for another nurse to take on IPC responsibilities at the university site later in the year, once service pressures related to the flu season and increased student registrations had eased.

Not all clinicians had received the recommended immunisations, and some immunity status checks were either outstanding or not recorded in staff files. While these checks were being completed for new starters in line with assessment findings, overall immunisation records remained incomplete. We identified evidence of some Hepatitis B vaccinations; however, records for other required immunisations were not consistently available. In addition, risk assessments for a non‑clinical staff member reviewed were not present within their personnel file.

The infection control assurance tool for the main site was completed in March 2025; however, it contained several gaps, including incomplete sections. A comprehensive IPC audit was completed in February 2023 for both the main site and the university site. An updated audit was overdue at the time of our assessment. Compliance scores were 75% for the university site and 66% for the main site. The audit identified several shortfalls, including the absence of a sharps management risk assessment and posters, staff awareness of how to access the IPC policies and gaps in their awareness of correct IPC procedures. The practice told us that an action plan had been completed to address these findings and mitigate risk; however, this was not provided during the assessment.

However, following our observations on the day of the assessment, we found that the issues previously identified in the action plan, had already been addressed by the practice; therefore, the practice should ensure this was documented in the action plan. For example, sharps‑injury posters had been put in place and overall, we did not observe any infection prevention and control shortfalls at either site during our onsite visits. A sharps audit had also been carried out and cleaning schedules were now in place. The practice had also taken steps to ensure the wheelchair stored at the entrance of the main site had a scheduled cleaning programme. We also saw effective arrangements to manage clinical specimens safely.

Despite these governance weaknesses, we observed that previously identified risks had largely been mitigated and the practice had processes for new starters and had begun addressing identified gaps in immunisations for staff. The environment across both sites was clean and well maintained, with appropriate arrangements for sharps management, cleaning schedules and the safe handling of clinical specimens. The practice had taken responsive action to address earlier shortfalls, which provided assurance that infection control risks were being effectively managed in day-to-day practice, although further work was required to strengthen documentation and assurance systems.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning and helped them 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. Systems for oversight of patient safety alerts required strengthening.

Staff received regular training, were competency assessed on medicines optimisation and felt confident. Prescribing staff told us they felt well supported. Clinicians took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics and prescribing data reviewed as part of our assessment confirmed this. For example, the number of antimicrobials and multiple psychotropics issued by the practice were lower than local and national averages and were positive outliers in 3 indicators. This included the prescribing of opioid and non-opioid analgesics, especially Gabapentin and Pregabalin, which can lead to dependency and serious harm. There was a quality improvement programme, including clinical audits of prescribing, that focused on improving care and treatment.

We saw good practice in relation to the prescribing of high-risk medicines. The monitoring of disease-modifying anti-rheumatic drugs (DMARDs) was generally effective. For example, our searches showed that all 37 patients prescribed methotrexate and the single patient prescribed leflunomide had received appropriate monitoring within the last 6 months. Of 17 patients prescribed azathioprine, two were initially identified as overdue; however, 1 had not received treatment since April 2025 and was likely no longer under the care of the practice and the other had appropriate monitoring completed but not recorded on the system. Overall, the provider demonstrated strong oversight of DMARD monitoring.

When we looked at inhaler usage, our searches showed no patients using 12 or more short‑acting beta agonist (SABA) inhalers in the past 12 months, which represented strong prescribing control and a high standard of asthma management, particularly within a student population. Searches also identified 4 out of 42 patients prescribed aldosterone antagonists for heart failure were overdue monitoring; however, records review confirmed all had blood tests completed within the previous 10 months and had been recalled for repeat monitoring.

Other searches showed generally good oversight, with isolated cases requiring follow-up, including one patient whose metformin was appropriately stopped following acute renal deterioration, with post-discharge review and ongoing specialist management in place.

All 3 patients prescribed lithium had recent drug level monitoring, although 1 required calcium monitoring. Of the 307 patients prescribed direct oral anticoagulants (DOACs), all had a creatinine clearance recorded, with 9 not recorded within the past year and 17 appearing overdue for blood test monitoring; however, these searches were not reviewed in detail. This suggests generally effective monitoring arrangements for this patient group, although a small proportion may require follow-up to ensure timely review and mitigate potential clinical risk.

Searches identified 13 of 1,058 patients prescribed ACE inhibitors to treat heart failure and high blood pressure were overdue monitoring, representing a low proportion. Of 4 patients prescribed amiodarone, 3 were fully monitored. Overall, systems for monitoring high-risk medicines were effective, with only small numbers of patients requiring further review and no significant delays identified.

Searches identified 88 patients at risk due to lack of gastroprotection; a review of 5 records showed 4 without cover, including higher-risk patients. Following the assessment, action was taken by the practice with most of these patients reviewed or addressed, though 13 remained under ongoing review to ensure safe prescribing.

However, there were some gaps in medicines optimisation systems in the practice. When we looked at the management of drug safety alerts, the practice told us that managers received the incoming alerts and disseminated them to the pharmacy team for actioning if relevant, consistent with the medicines policy. We spoke with 2 clinicians, including one pharmacist, and one non-clinician who were not clear on the process or how these alerts were shared with relevant staff. There was no alerts monitoring log in place, which meant the practice could not provide assurance that all alerts had been reviewed, or ensure actions were consistently tracked and followed up to reduce potential patient safety risks.

However, the evidence reviewed indicated alerts were generally actioned appropriately and we found overall good compliance with the management of MHRA alerts.

Searches identified some patients prescribed mirabegron, used to treat an overactive bladder, without recent blood pressure checks, with 8 of 43 appearing overdue. However, records reviews showed that 1 patient had not received the medicine since 2023 and the remaining 4 reviewed patients had blood pressure recordings within the last 18 months. This indicates that monitoring was broadly in place, although more timely checks could be strengthened. We also saw other examples where MHRA safety alerts demonstrated good compliance and the overall systems to respond to MHRA alerts were effective, with only minor areas identified for improvement.

Our searches also found 357 patients had a coded medication review in the past three months, which appeared low for the practice list size. The practice told us this may not reflect actual activity, as medication reviews are not always consistently coded following changes to quality reporting requirements. They also advised that clinical pharmacists routinely use a code for “medication review of medical notes” when accessing records, which may not represent a full structured review and can extend review dates on the clinical system. This reduced assurance that medication reviews were consistently recorded and accurately reflected clinical oversight, creating a risk that some patients may not receive timely, comprehensive medication reviews or that monitoring systems may not reliably identify those requiring review.

The practice held the appropriate emergency medicines at the practice and risk assessments were in place for those not on the recommended list; for example, they had undertaken a risk assessment regarding the absence of morphine for severe pain relief and naloxone used for opioid overdose. However, we found governance gaps in the checking of emergency medicines, with incomplete records and missing initials on several dates; for example, 24 March, 12 May and 24 May 2025. This reduced assurance that emergency medicines checks were consistently completed and created gaps in accountability and auditability.

Staff followed protocols to ensure they prescribed all medicines safely. There was a prescribing policy; however, it did not provide information regarding how they could access their Controlled Drugs Accountable Officer (CDAO). Medicines including controlled drugs were stored securely and at appropriate temperatures; however, emergency medicines were kept locked at the university site, which may delay timely access to treatment in an emergency and required further consideration.

Staff had the appropriate authorisations to administer medicines, including Patient Group Directions or Patient Specific Directions. Cold chain arrangements for the vaccines fridges were managed safely. There was also an effective system in place to monitor blank prescriptions.

Feedback from patients around medicines management was generally positive; however, 1 negative feedback reported difficulty obtaining medication over a 3 week period due to confusion around a shared care agreement, which caused stress and placed them at risk of going without treatment.

Care home feedback was positive, reporting regular medication reviews, effective monitoring through external services, and timely processing of prescriptions, supported by good communication between the practice, pharmacy and partner services, with no significant issues identified.