Southfields Group 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 patients 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, however there were some areas that the practice needed to improve.
The service had a good learning culture and patients could raise concerns. Managers investigated incidents thoroughly. Patients were protected and kept safe. Staff understood and managed risks. The facilities and equipment met the needs of patients, were clean and well-maintained and any risks mitigated. There were enough staff with the right skills, qualifications and experience. In most cases managers made sure staff received training and appraisals to maintain high-quality care. At the time of the inspection, not all staff had completed role specific training or had an appraisal in the last 12 months (although the practice had scheduled appraisals for these staff. Overall staff managed medicines well and involved patients in planning any changes.
 

This service scored 66 (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. All staff including those in non-clinical roles were made aware of significant events.
They listened to concerns about safety and investigated and reported safety events. The significant event policy had been reviewed in January 2026. We saw meeting minutes where significant events had been discussed, and actions taken to prevent the event happening again. Lessons were learnt to continually identify and embed good practice.

Patients felt supported to raise concerns and felt staff treated them with compassion and understanding. Staff we spoke with indicated they were happy with the way the practice responded to and supported them when things went wrong. There were systems in place to ensure learning was shared.
Representatives from the patient participation group (PPG) felt the provider took concerns seriously and proactively made improvements to the service.
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 patients support. We reviewed the complaints log, and it was managed in line with our expectations. Learning from incidents and complaints resulted in changes that improved care for others.
 

The service worked with patients 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 patients moved between different services.
There were systems in place for processing information relating to new patients.
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 practice had robust systems in place for reviewing laboratory results. Our review from clinical searches confirmed that results were processed in a timely way. GPs did their own referrals and for safety netting the admin team would run regular searches to make sure the practice had received a response. GPs also kept their own spreadsheet for all urgent 2-week referrals.
 

The service worked with patients and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving patients’ 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. GPs told us they had regular multi-disciplinary meetings with health visitors and school nurses to discuss child safeguarding concerns.
Safeguarding policies were in place and known to staff, who were in most cases appropriately trained in safeguarding procedures. The practice maintained a list of vulnerable patients and acted on concerns working in partnership with other organisations. We saw the practice made effective use of alerts, and codes on their system to identify vulnerable patients.
Although the adults safeguarding policy had been reviewed in May 2025 and the child safeguarding policy had been reviewed in January 2026, they made reference to incorrect staff training levels contra to the intercollegiate guidance. At the time of the inspection some staff had not been trained to the correct safeguarding levels, for example out of 5 files we checked 3 non-clinical staff were trained to level 1. Once we raised this with the practice, they told us they would review their policies and we saw they got staff to complete the required level of training.
 

Data from the GP Patient survey 2025 showed a total of 97% of respondents stating they were involved as much as they wanted to be in decisions about their care and treatment during their last general practice appointment. This was above the local average of 92% and national average of 91%.
The service worked with patients to understand and manage risks by thinking holistically. They provided care to meet patients’ needs that was safe, supportive and enabled patients to do the things that mattered to them.
Emergency equipment was available and maintained. This included having 2 oxygen cylinders and a defibrillator.
Staff could recognise a deteriorating patient and knew of action to take, however not all non-clinical staff had completed sepsis awareness training. Patients were advised on risks related to their condition and actions to take if their condition deteriorated
Most staff had completed face to face basic life support training on an annual basis, the practice had to taken action to follow up the staff that were unable to attend.
 

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. The practice manager had good oversight of the maintenance contracts in place. We saw that fire, and electrical maintenance contracts were well monitored, and checks were carried out in a timely manner. We saw a certificate for Portable Appliance Testing (PAT) equipment dated May 2025. We saw certificates for calibration of equipment dated January 2025. 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 service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development, however we found that not all staff had an appraisal in the last 12 months. When we raised this with the practice they informed us they were aware and had scheduled meetings in the next few weeks with all staff who had not had an appraisal. Staff worked together well to provide safe care that met patients’ individual needs.
There were a range of clinical and non-clinical roles within the practice. We found generally training was up to date, learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence. We were told non-medical prescribers had regular supervision; however this was not formally documented. When we raised this with the practice they said they would start to document supervision.
The recruitment policy had been reviewed in January 2026. Safe recruitment practices were followed in most cases, the practice ensured that staff employed were employed in line with safer recruitment processes. However out of 5 files checked we did identify 1 clinical staff member who the practice did not obtain a CV or application or any references. When we raised this with the practice they told us the staff member was known to the practice. Shortly after the inspection the practice did obtain a CV and references. We also found that 2 staff members had not signed a confidentiality agreement.
Some staff members had not completed role specific training for example sepsis awareness, mental capacity, and correct levels of safeguard training.
 

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.
Staff vaccination status was confirmed at recruitment however risk assessments were not in place for non-clinical staff who were unable to confirm childhood vaccination status.
 

The service generally made sure that medicines and treatments were safe and met patients’ needs, capacities and preferences. Overall, they involved patients in planning, including when changes happened.
Clinical searches identified most monitoring was appropriate and completed in recommended timescales however, recommended guidance was not always followed with patients prescribed certain medicine. For example, we reviewed the records of 3 patients on a medicine used to treat chronic inflammatory conditions. We found with all 3 patients there was no evidence that the prescriber had checked the patients monitoring was up to date prior to issuing a prescription.
We reviewed the records of 3 patients on a medicine used to treat and prevent serious, life-threatening heart rhythm disorders; we found that with all 3 patients they were not being monitored as required.
When we raised this with the practice, they explained they were previously using 2 pharmacists to run searches, monitor and contact patients, however they were both on maternity leave. Consequently, the practice had been running searches using an admin person, but this was not being done to the same level. They were intending on recruiting another pharmacist to cover the maternity leave.

Staff involved patients in reviews of their medicines and helped them understand how to manage their medicines safely.

Patients 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 patients received all recommended medicines reviews and monitoring. Medicines including controlled drugs were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines, vaccines, and controlled drugs. For example, our review of vaccines stored in the fridge showed that they were stored at the appropriate temperatures and staff has robust systems in place to ensure they maintained efficiency. This included daily logs of maximum and minimum fridge temperatures. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments. The provider had effective systems to manage and respond to safety alerts and medicine recalls. Staff followed established processes to ensure patients prescribed medicines with specific risks received recommended monitoring. 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 lower than local and national averages.
There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.