Riverside 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 has changed to requires improvement.

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

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.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. Managers encouraged staff to raise concerns when things went wrong. During staff meetings, the whole team discussed and learnt from clinical issues. Staff felt there was an open culture, and that safety was a top 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.

The service did not maintain safe systems of care. They did not make sure there was continuity of care when people moved between different services.

On review of clinical systems on 8 December 2025, 1,080 tasks were identified as incomplete, dating back to 2012. This was immediately escalated to practice leaders. At the time of the site visit on 10 December 2025, immediate action had been taken by leaders to action all outstanding tasks.

The practice did not always make sure there was continuity of care when people moved between services. On review of clinical records, we saw that people were supported to consider their wishes for their end-of-life care, including cardiopulmonary resuscitation. However, for people who had a DNACPR form in place, a copy of the form was not always attached to their clinical records.

There were systems in place for processing information relating to new patients. The practice had recently merged with another practice prior to our assessment. We saw that the service had processed patient information appropriately. 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.

The National GP Patient Survey 2025 data showed that 58% of respondents usually got to see or speak to their preferred healthcare professional when they wanted to. This was higher than the national average of 40%.

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. 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.

Emergency equipment was available and maintained. Staff could recognise a deteriorating patient and knew of action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated

The National GP Patient Survey 2025 data showed that 92% of respondents were involved as much as they wanted to be in decisions about their care and treatment during their last GP appointment. This was higher than the national average of 91%.

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. Health and safety risk assessments and audits had been undertaken and risks identified had been addressed. There was a business continuity plan in place.

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. Safe recruitment practices were not always followed.

There were no systems in place to record immunisations records of staff. The recruitment policy did not contain any information relating to staff immunisations.

There were a range of clinical and non-clinical roles within the practice. This included 4 GPs, 3 Practice Nurses, 2 Advanced Clinical Practitioners, 2 Paramedic Advanced Practitioners, and a Pharmacist. 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. There was a risk assessment in place and documented consideration of safe staffing levels within the practice. We saw examples of staff development within the practice, through apprenticeships and management training courses.

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.

The practice had a designated infection, prevention and control lead and all staff had had relevant training. Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks.

Safe systems were not always in place to check the practice premises. We saw 2 sharps bins that had been left open on the day of the inspection. We informed staff of this on the day of inspection, and immediate action was taken by staff to make the sharps bins safe. New signage was also put up by Practice Leaders to remind staff to close sharps bins.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

The practice did not have safe systems to process PGDs. We saw that 22 PGDs had been signed by the authorising manager prior to being signed by practitioners. This meant the practitioners had not been formally authorised by the authorising manager as being trained and competent to use the PGDs before doing so.

Medication reviews were not always comprehensive. They did not aways include a review of all a person’s medicines or ensure that all recalls were up to date at the time of the medication review. Staff did not always involve people in reviews of their medicines.

Staff regularly checked the stock levels and expiry dates for emergency medicines. The provider had effective systems to manage and respond to safety alerts and medicine recalls.