Heathcot 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.

The practice had established processes for learning from complaints and significant incidents. They had identified and acted to protect vulnerable patient groups. However, we identified areas where systems and processes had not always been reliable in keeping people safe.

At our last assessment, we rated this key question as requires improvement. At this assessment, the rating has changed, the service has made improvements and is now rated good.

However, the service remains in breach of legal regulation in relation to safe care and treatment.

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 practice 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. People felt supported to raise concerns and felt staff treated them with compassion and understanding.

Patients and their carers were provided with information about how to make comments or complaints. This information was available at each surgery and on the practice website. There was a system to record and investigate complaints and, when things went wrong, staff apologised and gave people support. The practice had identified a theme from the complaints received regarding repeat prescribing, and the practice had improved their processes and patient information as a result.

The practice provided records for significant events logged during the last 12 months. By sampling 3 entries, we found these were recorded and investigated appropriately. Learning was shared throughout the practice which resulted in improved care for others.

A process for handling safety alerts was in place and followed. This meant staff were aware of alerts and able to action necessary changes, to keep people safe.

The practice worked with people and healthcare partners to provide continuity of care but had failed to establish and maintain safe systems of care. They did not manage or monitor people’s safety effectively.

A process was in place for the allocation of pathology results; however, this system was not working as intended. Urgent results were reviewed by the duty doctor. Discharge summaries from hospitals were coded by administrators and assigned to a clinician to action, through the clinical system.

We reviewed the system to manage clinical tasks and found a large number of tasks outstanding. We found some of these were tasks requiring action, including some pathology results and one referral was missing information. The practice was unable to demonstrate their assurance of action having been taken to resolve the tasks, which meant patients could be at risk of harm. Furthermore, management did not fully understand the oversight capabilities of their clinical system or their responsibilities to ensure tasks were completed. The GP partners took action during our site visit to review these tasks, and no evidence of harm was found.

We found cervical cytology results had not always been checked or actioned. One was overdue from November 2025. The practice did not have fail-safe systems in place in line with national guidance, to ensure all cervical cytology results were received from samples sent. This could cause delays to necessary treatment.

The practice 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 practice shared concerns quickly and appropriately.

Safeguarding policies were in place and known to staff. Staff were trained in safeguarding vulnerable adults and children to appropriate levels for their role. The practice maintained a list of vulnerable people, identified them with digital flags and acted on concerns, working in partnership with other organisations. A GP was assigned the role of safeguarding lead and had dedicated slots each day to address safeguarding concerns. A deputy safeguarding lead was also nominated to ensure continuity of care. Staff were aware of who the safeguarding leads were.

The practice followed up on child attendance at accident and emergency departments and displayed local support services for domestic violence in each surgery.

The practice 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. The practice had a duty doctor each day to support with any patients who needed urgent action. Staff had been trained to recognise symptoms which may need urgent medical attention. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

The practice did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

During our visit we found correct signage was not installed to identify hazardous substances in line with COSHH regulations (control of substances hazardous to health). Since our site visit the practice has provided evidence that appropriate signage has been installed.

Directly before our visit, the practice had arranged a contractor to undertake fire risk assessments. This had identified concerns at all 3 sites, including soft furnishings potentially not meeting fire retardant standards and non-compliant doors and construction.

We were not assured there were always effective processes of risk assessment or that the practice maintained oversight of the risks, to manage or reduce them.

The practice did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development.

Staff worked together to provide safe care that met people’s individual needs, but training, recruitment and staff immunisation policies were not always followed.

We sampled staff recruitment records and found that one lacked all of the required information. Multiple training records contained gaps meaning that some staff may not be up to date with necessary skills. Staff immunisation records were incomplete, and governance systems had not identified or mitigated risks arising from this. We made the practice aware of our findings, and they agreed to review and address these issues. Following our site visit, risk assessments and evidence of recruitment records, which previously had gaps, were provided and leaders in the service described actions taken to strengthen their processes and ensure patient safety.

Clinical supervision and appraisals were undertaken for staff, and clinical staff worked within agreed competencies. Audits were undertaken of non-medical prescribing to ensure adherence to current guidelines, and to maintain patient safety.

Staff told us they had been supported to undertake external training to support them in their roles and for their career development.

The practice 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 understood their responsibilities. Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks.

The practice 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.

As part of our assessment, a CQC GP specialist advisor undertook clinical record searches. This compared the practice’s procedures around prescribing and medicines management to recognised standards. We found that patients on medications that require monitoring were recalled and assessed in line with guidance.

Staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely. Those with long-term conditions were recalled for their annual review in their birth month and assessed using templates that reflect national guidance for disease management.

People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms.

The practice had effective systems to monitor and review emergency medicines and equipment. Medicines were stored securely and at appropriate temperatures.

The practice had effective systems to manage and respond to safety alerts and medicine recalls. Staff managed prescription stationery appropriately and securely.

There was a programme of regular clinical audits of prescribing that focused on improving care and treatment. Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics.