Windhill Green 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

The service had an embedded learning culture, and patients could raise concerns. Leaders and managers investigated incidents thoroughly. Patients were protected and kept safe. Staff understood and managed risks. The facilities and equipment met the needs of patients who used the service and were clean and well-maintained. There were enough staff with the right skills, qualifications and experience. Staff received training and regular appraisals to maintain high-quality care. We saw that staff managed medicines well and involved patients in planning any changes.

At our last assessment, we rated this key question as good. At this assessment, the rating remains the same.

This service scored 75 (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 strong proactive and positive culture of safety, based on openness and complete honesty. Staff actively listened to concerns about safety and thoroughly investigated and reported safety events. Lessons were always learnt to continually identify and improve services. We saw that the principles of continuous learning and quality improvement had been embedded across the practice and at all levels. Patients were supported to raise concerns, and we saw that information was available to patients about how to raise concerns and complaints. This included details on the practice website and information contained in a complaints leaflet.

Staff we spoke with had a good understanding of how to support patients who raised concerns and knew how these should be recorded. In the previous 12 months the practice had received 45 complaints. We examined 2 of these in detail and saw that they had been handled appropriately, and informed patients of escalation routes they could access should they remain unhappy with the outcome. Complaints we reviewed were thoroughly investigated, and we saw that learning from them was used to improve services. For example, a complaint had led to the standardisation of communication regarding vaccine refusals.

As well as individual learning the practice carried out an annual review of all concerns to identify themes. Following reviews of patient feedback regarding access concerns and especially issues contacting the service by telephone we saw that in late 2024 the practice had installed a new telephony system to ease contact, and which included a call back option.

Managers encouraged staff to raise concerns when things went wrong and record these as significant events. Learning events were shared with staff at team meetings, this included specific meetings for significant events and learning. We saw evidence from minutes of meetings which corroborated this. The practice had identified recurrent themes over the previous 2 years. This included women prescribed oestrogen only HRT (a treatment that uses oestrogen to replace the declining levels of this hormone during menopause), who had inadequate progesterone cover. After reviewing this the practice added a screen pop-up message to alert prescribers of the need to check this before signing off a prescription for oestrogen only HRT.

Continued learning was supported by a programme of clinical and non-clinical audits which included prescribing audits, audits into information access requests, and home visit requests. To emphasise and increase learning opportunities the practice held monthly educational meetings which discussed new learning, audits, and cases of interest. Staff we spoke with told us that they found these valuable and led to improved care and treatment.

The service worked with healthcare partners to establish and maintain safe systems of care. They made sure there was continuity of care, including when patients moved between different services. There were systems in place for processing information relating to new patients joining the practice. At the time of our assessment there were 153 records awaiting summarisation against a patient list of over 24,000. The oldest record dated back to November 2024. Whilst awaiting summarising we saw that the practice had electronic health records available, and patients completed a new patient questionnaire which covered prescribed medicines, details of allergies and medical conditions. The practice told us that they had allocated additional trained staff to deal with this summarising, and progress was monitored at their monthly data team meetings.

The service worked with other providers to deliver integrated and joined up care, including when patients moved between services. For example, when a patient was discharged from hospital their care needs were reviewed, and if required, additional support could be arranged via their primary care network’s housebound visiting team or proactive care team (PACT). Local referrals were facilitated by using a standardised referral pathways template. The use of this template ensured patients were referred effectively and reduced the number of rejections. We saw that referrals and test results were managed in a timely way, and that high priority referrals including urgent cancer referrals were subject to regular monitoring checks to ensure actions had been taken.

The service worked with patients and care partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving patient’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

We discussed safeguarding with staff and found they had a good overall understanding of the subject and gave examples when they would raise concerns with managers and the 3 safeguarding leads within the practice. Safeguarding was supported by detailed policies and processes all of which had recently been reviewed. As well as safeguarding policies we saw that the practice had other related policies and procedures which included those related to domestic violence, and female genital mutilation. Checks on training records showed that staff had been trained in safeguarding to levels appropriate to their roles.

Safeguarding was discussed at monthly multi-disciplinary team meetings when cases of concern could be discussed with others, and at internal safeguarding meetings. The practice maintained a list of vulnerable patients and acted on concerns working in partnership with other organisations. We saw that the practice utilised their clinical system to support their safeguarding approach. For example, they recorded if a child was not brought in for an appointment and used this to track any developing concerns.

The service worked with patients to understand and manage risks. We saw that staff provided care to meet patient needs that was safe, and supportive. Results from the 2025 National GP Patient Survey showed that 94% of patients reported that they were involved as much as they wanted to be in decisions about their care and treatment during their last appointment, compared to local and national averages of 91%. Staff we spoke with could recognise the signs of a patient with deteriorating health and knew of the actions to take to keep them safe, and effectively respond to the situation. All sites had emergency equipment and medicines available, and we saw that these were regularly checked and maintained. Staff had all received necessary training in basic life support, and emergency procedures. Clinicians we spoke with confirmed that patients were advised on risks related to their condition, and actions to take if their condition deteriorated

The service worked to identify and control potential risks within the care environment. The service ensured that equipment and facilities supported the delivery of care and kept both patients and staff safe. The practice had put policies and processes in place which gave assurance that health, safety and wellbeing requirements were met. For example, we saw that the legionella policy had recently been updated, and that electrical installation checks had been carried out for all 4 sites. In addition, health and safety risk assessments had been undertaken and were available to staff on their shared compliance management system.

Regular maintenance, servicing and calibration of clinical equipment had taken place. We saw that fire safety risks were being managed, and that regular fire alarm checks and fire evacuation drills had been carried out. Staff with additional safety duties such as fire marshals had received training and instruction in how to fulfil these roles. The provider undertook their own regular health and safety checks, and we saw that they had taken appropriate action to rectify any concerns identified. However, we noted that in the staff parking area at the Windhill Green Medical Practice there was a minor trip hazard where some bollards had been removed. This was pointed out to the management team who told us that they would deal with this.

The service made sure there were always enough qualified, skilled and experienced staff, who received thorough support, supervision and development opportunities. They worked together to provide safe care that met individual needs.

Recruitment processes were in place, and from checks on recruitment files on the day of our onsite visit we found that recruitment records were comprehensive and complete, and included checks on qualifications and registrations, references, and disclosure and barring service clearance. We saw that induction processes were in place for new starters at the practice. This was supported by an induction policy that was detailed and included initial induction procedures, mandatory and role specific training, and ongoing supervision and review. Locums were also supported via an initial induction to the service and a locum pack which contained necessary key information which enabled them to effectively deliver their duties.

Staff had regular appraisals, one-to-ones, and access to mentorship when required. This was confirmed by staff that we spoke with or received questionnaires from during the assessment. Clinical and non-clinical supervision was embedded within the practice. The practice had developed and adopted a non-medical prescribing policy which included auditing of prescribing, and a clinical supervision policy which detailed the level of supervision required for each role. As a training practice measures were in place to closely support trainee GPs and medical and nursing students. This included clinical debriefing sessions and immediate on call support. Staff we spoke with told us that they were able to access advice and guidance from more senior staff when they required it.

The practice had forward planning measures in place which ensured that there were enough qualified, skilled and experienced staff on duty, this included planning staffing rotas up to 6 months in advance. The importance of succession planning and rising capacity needs had been recognised by the practice, and we saw that an additional 3 GPs had been recruited to cover planned retirement and other demands on capacity. Information from the practice showed that at the time of our assessment the practice had 1,987 patients per full time equivalent GP, compared to a British Medical Association derived average of 2,273 patients.

The practice had measures in place to manage infection prevention and control (IPC). IPC was overseen by a senior trained staff member who acted as the practice’s IPC lead. An IPC policy had been developed which covered all required areas such as cleaning and disinfection, training and clinical waste management. We saw that regular IPC audits, both in-house and externally organised, had been undertaken, and that when issues had been identified these had been tackled. For example, after an audit at the Windhill Green Medical Practice site in 2024 we saw that additional fittings had been added to the cleaning schedule. Staff we spoke with were able to explain how they would deal with spillages of bodily fluids, and we saw that spill kits were available to staff. Staff undertook IPC training during their induction and undertook refresher training on an annual basis.

Working via their occupational health provider we saw that as part of the recruitment process the practice had assurance that staff had received the necessary immunisations and vaccinations to undertake their roles safely.

Clinical waste was safely handled and stored; the practice had a clinical waste disposal contract in place and waste was picked up on a weekly basis.

We found standards of cleaning on the day of our site visits to be good. The practice reported that they worked closely with their cleaning contractor to maintain standards. Over recent years the practice had made substantial investments into their estates with a refurbishment of the Windhill Green Medical Practice, and a partial refurbishment of Cliffe Avenue Surgery. It was though noted that some of the consultation rooms in Cliffe Avenue Surgery and Saltaire Medical Practice were carpeted, which did not facilitate effective cleaning and disinfection. We were told on discussing this with the practice that these rooms were only used for general consultations and examinations and were not used for taking blood samples.

The service made sure that medicines and treatments were safe and met patient’s needs, capacities and preferences. They involved patients in planning, including when changes happened. We saw that staff from the practice and their supporting primary care network (PCN) involved patients in reviews of their medicines and helped them understand how to manage their medicines safely.

The practice approach to high-risk medicines monitoring was supported by a detailed protocol which set out actions for recalls and reviews including appointments, the handling of results, and shared care arrangements (a formal agreement where a specialist like a hospital consultant shares responsibility for a patient's care, particularly medication prescribing and monitoring, with their GP). The practice had developed and/or adopted safety pop-ups to alert staff to implement necessary checks or safeguards when prescribing certain medicines. In addition, the practice ran their own clinical searches to help them to assess and manageclinicalsafety and the effectiveness of care delivered.

As part of our assessment, a CQC GP Specialist Advisor (SpA) undertook remote clinical searches of patient records to assess patient care and medicines management. We found during the searches that patients and their medication needs had been well managed. For example, of 632 patients prescribed a Direct Oral Anticoagulant (a medicine used to prevent blood clots) only 1 patient had potentially not received the required monitoring. When we examined this patient’s records further, we saw that the monitoring had been undertaken, however a necessary calculation had not been undertaken to assess renal function. We also initially identified 6 out of 20 patients in receipt of Lithium (a medicine used to treat mood disorders) had potentially not been monitored. However, on checking with the practice we found that 3 had received appropriate monitoring in line with their local shared care protocol, and 3 patients had monitoring appointments booked. We found that the practice effectively managed patients in respect of the potential overuse of SABA (short-actingbeta-2agonist) inhalers and regularly used searches to identify and support these patients. They also participated in a local programme the Campaign to Help Improve Respiratory Prescribing (CHIRP), which improved clinical knowledge and monitoring processes.

The practice had effective systems to manage and respond to safety alerts and medicine recalls, and our remote clinical searches related to 2 separate alerts showed these had been effectively actioned. Safety alerts were also subject to regular in-house searches, and safety pop-ups had been developed as reminders to clinical staff.

Quality assurance was deeply embedded within the practice. For example, the practice had a programme of internal clinical and non-clinical searches, some which had been repeated 3 times to track improvement. They also participated in external audits including those linked to antibiotic prescribing and improving respiratory health. As noted, the practice undertook regular searches to assess key performance areas such as monitoring. On an annual basis the prescribing lead provided the clinicians with an overview of prescribing trends, including those related to good antibiotic stewardship. Non-medical prescribers were also monitored as part of their clinical supervision and ongoing support. The profile of medicines management was also high within the practice and was discussed at monthly clinical team meetings, as well as educational events.

Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines, and vaccines, and medical gases, such as oxygen were safely stored.