Woodsetton 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 72 (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. The provider had processes for staff to report incidents, near misses and safety events. There was a significant events policy, and a reporting process in place, which was accessible to all staff members. Staff felt there was an open culture, and that safety was a top priority.

There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Information reviewed demonstrated that people had opportunities to provide feedback and they knew how to make a complaint. Lessons were learnt from individual complaints and shared with the practice team to improve the quality of care. Feedback and information were available in the practice and on their website.

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 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. We found systems were in place to ensure referrals and test results were managed in a timely way.

The provider was part of the Primary Care Network (PCN) and attended regular meetings with other agencies across the locality to share and discuss information relating to patient care and treatment, for example, people on the practice palliative care register.

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 a range of structured meetings in place. These included safeguarding, multi-disciplinary and practice team meetings.

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 provider regularly liaised with multi-disciplinary teams to coordinate and safeguard individuals at risk.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. The practice maintained a register of vulnerable individuals and responded proactively to concerns, implementing actions and learning in collaboration with partner organisations.

Safeguarding was reviewed, and relevant information was shared amongst the team. Vulnerable patients were appropriately coded; however, they were not always linked to household members. We discussed this with the provider who agreed to action.

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. Staff were aware of the location of the emergency medicines and medical equipment, for example oxygen and the Automated External Defibrillator (AED).

Patients were provided with advice regarding risks related to their condition and informed about actions to take should their health deteriorate. Staff demonstrated understanding of emergency protocols and were able to activate the integrated panic alarm system when required.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

During our site visit we found the premises were well maintained. The provider detected and controlled potential risks in the environment. They made sure equipment, facilities and technology supported the delivery of safe care. Regular checks were carried out on the premises, facilities and the equipment provided. Contracts were in place to ensure the premises were clean and well maintained. Clear signage around the building supported people and staff in the event of an emergency evacuation.

There was a business continuity plan in place which was monitored and reviewed. Reception and administration staff who handled calls to the practice and arranged appointments with the clinical team were aware of potential red flag symptoms. They knew when to notify a GP or other clinicians with concerns about a patient who may be acutely unwell and/or deteriorating. Staff had been provided with training in health and safety related topics such as fire safety, infection control, basic life support and resuscitation training.

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 practice. 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 regular supervision of non-medical prescribers and systems in place for the monitoring of staff. 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.

Safe recruitment practices were in place. Staff immunisation status records were maintained, and appropriate pre-employment checks had been completed. Where required, individual staff risk assessments had also been carried out.

The practice had clear recruitment policies, and all staff had either completed disclosure and barring checks or had a documented risk assessment. A review of four personnel files confirmed that appropriate checks, including verification of previous employment history undertaken.

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. The most recent audit, completed in June 2025, showed the practice had achieved a compliance score of 92%. Areas identified for action included replacing carpeted flooring in clinical rooms and ensuring all chairs were wipeable. These improvements were in progress at the time of our assessment. Cleaning schedules were in place and followed.

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.

The practice was supported by clinical pharmacists from the local Primary Care Network (PCN) to monitor people and the prescribing of medicines.

We carried out remote searches of clinical records as part of our assessment to check how the practice monitored patients’ health in relation to the use of high-risk medicines. Our remote clinical searches found 765 patients had received a medication review in the previous 3 months. We found that staff followed established processes to ensure people prescribed medicines with specific risks such as Methotrexate (an immune system suppressant drug) received the recommended monitoring.

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. 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. Emergency medicines were in place; however, one recommended item was not available at the time of inspection, nor had been risk assessed. The practice confirmed they would take action to determine whether the medicine should be appropriately stocked.

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 people 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, hypnotics, psychotropics, Pregabalin or Gabapentin’s issued by the practice were in line with national averages. There were regular clinical audits of prescribing that focused on improving care and treatment.