Mayfield 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 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 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 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.

Managers encouraged staff to raise concerns when things went wrong. During staff meetings, the whole team discussed and learnt from significant events and clinical issues. Staff felt there was an open culture, and that safety was a top priority. The service 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.

Representatives from the Patient Participation Group (PPG) felt the service took concerns seriously and proactively made improvements to the service. For example, the service purchased a touchscreen tablet computer for the reception area. This was used by people who did not have any technology. They were able to access the online triage and consultation system for booking appointments and ordering medications.

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 for processing information relating to people who were newly registered at the service. 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, with cover arrangements during staff absences.

Feedback we received from care home staff confirmed that the service worked effectively with external services and followed up referrals promptly. This supported continuity of care and helped to minimise delays in people receiving the care and support they needed.

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.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. Staff we spoke with were able to explain the safeguarding processes and were confident in raising any concerns to the nominated safeguarding leads. The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations.

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.

Staff could recognise a deteriorating patient and knew of action to take. Staff had access to an emergency alert button on the computer system, enabling them to call for assistance quickly when required. The service had a daily acute team on duty, which consisted of 3 GPs who were available for appointments, advice and support as necessary.

Emergency equipment was available and maintained. The service held appropriate emergency medicines and equipment at both sites which had regular checks.

People were advised on risks related to their condition and actions 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.

Contracts were in place to ensure the premises were maintained. Legionella (a bacteria which can cause breathing problems) and Health and safety risk assessments and audits had been undertaken and risks identified had been addressed. There was a business continuity plan in place which was monitored and reviewed.

The last fire risk assessment was completed in December 2025 for both Mayfield Medical Centre and the Cherrybrook Branch. We saw fire exits were clear, and fire equipment was easily available and was regularly maintained by an external company.

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 service such as GPs, nurses, phlebotomists and pharmacy technicians. 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.

Staff had regular appraisals to discuss their performance, learning needs and aspirations for the future. Staff were upskilled to support the service and their professional development. For example, the service provided protected time to support staff who wanted to undertake training to become a phlebotomist (a person trained to take blood samples).

Safe recruitment practices were followed. We reviewed a number of staff files which contained the appropriate documentation in line with national legislation. Managers were able to demonstrate how they reviewed staff rotas to address demand and how they covered busy periods such as annual leave and staff sickness.

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.

Facilities and equipment were maintained in line with manufacturer’s instructions and underwent scheduled servicing at regular intervals. Risk assessments and audits were completed, and actions taken to mitigate risks.

During our onsite visit, the service's premises and a sample of equipment reviewed was noted to be visibly clean. Personal Protective Equipment (PPE) was available to staff and there were hand washing facilities in all clinical areas. The service used an external cleaning company and had cleaning schedules available.

The service had a designated Infection, Prevention and Control (IPC) lead and all staff had had relevant training.

Sharps waste bins used for disposing of used medical instruments such as needles or syringes were safely secured and managed.

The service 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 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, were competency assessed on medicines optimisation, and felt confident managing the storage, administration and recording of medicines.

Staff managed prescription stationery appropriately and securely. Staff followed protocols to ensure they prescribed all medicines safely, and ensured people received all recommended medicines reviews and monitoring.

Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines, vaccines, and controlled drugs. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments.

The service had effective systems to manage and respond to safety alerts and medicine recalls. Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring. For example, people who were prescribed a medicine to treat autoimmune conditions such as rheumatoid arthritis had received blood test monitoring within the recommended timescales.

As part of our inspection, a set number of clinical record searches were undertaken remotely by a CQC GP specialist advisor. We sampled 5 clinical records to look at the quality of medicine reviews and found all of them to be appropriately reviewed and in line with people’s needs.

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 number of antimicrobials issued by the provider was in-line with local and national averages.

There was a programme of regular clinical and non-clinical audits that focused on improving care and treatment. For example, non-medical prescribers (NMPs are healthcare providers who are qualified and authorised to prescribe medicines) audits were carried out to ensure that the prescribing was safe, appropriate and in-line with national and local guidance.