Jorvik Gillygate 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 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.

Jorvik Gillygate Practice had a proactive and positive culture of safety, based on openness and honesty. It listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

In feedback to CQC, all staff who responded confirmed that they knew how to report a significant event. Most stated that they were invited to discuss significant events and that learning was shared with them.

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

The practice had processes for staff to report incidents, near misses and safety events. There was also a system to record and investigate complaints, and when things went wrong, staff apologised and offered people support.

Learning from incidents and complaints resulted in changes that improved care for others.

Jorvik Gillygate Practice worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. It 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 practice worked with other providers when patients moved between services and to deliver shared care.

We saw that referrals to secondary care and test results were managed in a timely way and that there were arrangements to distribute internal tasks when staff were absent or on leave.

We also saw that there were systems and processes in place to deal with Medicines and Healthcare products Regulatory Agency (MHRA) alerts.

Jorvik Gillygate Practice worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. It concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect.

Safeguarding policies were in place and were known to staff who had received training in safeguarding children and adults at a level relevant to their role. One of the GPs was the safeguarding lead for the practice and there was a deputy in place for continuity. Safeguarding was a standard agenda item for all clinical meetings.

In feedback to CQC, all staff stated that they knew who to report safeguarding concerns to and most staff stated that they were confident in identifying safeguarding issues.

Chaperones were available at the practice and both clinical and non-clinical staff had received training in this area. The practice website contained clear information on the chaperone policy and there were notices in consultation rooms and reception advising patients that they could request a chaperone should they wish to do so.

‘Learning disabilities and Autism’ training was mandatory for all staff, and all staff had completed it.

There was a clear ‘Child not brought’ policy for children who did not attend appointments at the practice or hospital. If this happened, attempts would be made to contact the family to understand why. If contact could not be established, or if there were safeguarding concerns, the practice safeguarding lead would then be informed.

Jorvik Gillygate Practice worked with people to understand and manage risks by thinking holistically. It provided care to meet people’s needs that was safe, supportive, and enabled people to do the things that mattered to them.

Emergency equipment (such as emergency medicines and a defibrillator) was available at each site and was routinely checked and maintained. It was stored in central locations and in feedback to CQC, staff told us that they could easily access it.

All staff had completed Sepsis training so that they could recognise a deteriorating patient, plus training in basic life support and anaphylaxis.

Patients were advised on risks related to their condition and what action to take if their health deteriorated.

Jorvik Gillygate Practice detected and controlled potential risks in the care environment. It made sure equipment, facilities and technology supported the delivery of safe care.

Contracts were in place to ensure each of the 3 sites were well maintained and a health and safety risk assessment, legionella risk assessment, fire risk assessment, and Control of Substances Hazardous to Health (COSHH) risk assessment had all been undertaken within the last year to identify potential risks to staff or the public.

Portable appliance testing and calibration of equipment were both up to date and regular fire safety checks were conducted at each site. Most staff had completed fire awareness safety training. Those that had not, had been enrolled on the course and completion was being monitored.

There was a business continuity plan in place which was regularly monitored and reviewed. This included contingency plans in the event of an incident such as a fire or flood, loss of utilities, loss of the internet/internal systems or loss of access.

The practice also had a clear policy in place to ensure the safety of staff supporting patients registered under the NHS Special Allocation Scheme (SAS). These patients are typically removed from other GP practices due to violent or threatening behaviour and to protect staff and other patients, the practice had implemented several measures. These included a designated phoneline, reserved appointments at the end of the day, ground‑floor consultations with SAS‑allocated doctors, and only allowing one SAS patient in the building at any given time.

In feedback to CQC, staff told us that they were happy with the health and safety arrangements at each practice site.

Jorvik Gillygate Practice 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.

We found most 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 policy for clinical supervision and competency of all clinical staff and staff confirmed that the practice had an open-door policy and that support was available should they need it.

GP Registrars were appropriately supervised, with dedicated debrief slots at the end of each session to discuss cases and receive feedback.

Although some staff stated that they would benefit from more protected time to complete administrative duties and learning and development, most stated that they were given time for these tasks.

Safe recruitment practices were followed. These included appropriate levels of Disclosure and Barred (DBS) List checks.

A DBS check is a criminal record check in the UK used to help employers determine if someone is suitable and safe for a role and is particularly used for roles involving children, vulnerable adults, or sensitive information.

Jorvik Gillygate Practice assessed and managed the risk of infection. It detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

There was a designated infection, prevention and control (IPC) lead and they were supported by both a clinical and an administrative team member who had undertaken IPC training to lead level, thereby ensuring continuity and no gaps in cover.

Staff completed regular audits of the premises. These included audits of staff procedures (such as handwashing and use of personal protective equipment) alongside audits of waste, equipment, and the care environment. The most recent audit had been completed in March 2026 and showed acceptable standards of IPC with minimal remedial actions required.

IPC training was mandatory for all staff and all staff had completed it.

In feedback to CQC, staff stated that they were aware who the IPC lead was and that they felt that IPC arrangements were sufficient to protect staff and patients.

Cleaning schedules were in place and were followed across all 3 practices. Where carpets were used in clinical rooms, there was a risk assessment in place alongside a regular cleaning programme.

While on site at Woolpack House and South Bank Practice, we observed both practices to be clean and tidy throughout.

While a number of positives were noted, Jorvik Gillygate Practice did not always ensure that medicines and treatments were safe and met people’s needs, capacities, and preferences.

As part of our assessment, a series of patient clinical record searches were undertaken by a CQC GP specialist advisor. This included a review of the management of patients on a sample of medicines that require monitoring as well as a review of prescribing, including the effectiveness and quality of medicine reviews and usage.

These clinical searches showed that, in many cases, patients’ health was monitored in a way that ensured the safe prescribing of certain medicines. For example, patients prescribed methotrexate (a medicine used to treat pain and stiffness in joints caused by inflammation); and patients prescribed aldosterone antagonists (medication used to prevent and treat blood clots) were both noted to be monitored well.

However, some areas for improvement were also identified, for example:

• We identified 4 patients with asthma who had been prescribed 2 or more courses of rescue steroids in the last 12 months who had received inconsistent follow-up appointments which were not in line with current national guidance: and
• We identified 5 patients prescribed SGLT2 inhibitors (medication primarily used to manage blood sugar levels in people with type 2 diabetes) who had either been given no advice or no recent advice about the risks associated with their medication.

When these findings were shared with the practice, they were immediately investigated with steps taken to resolve any issues identified.

On a positive note, it was noted that 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 also received regular training in medicines, were competency assessed on medicines optimisation, and felt confident managing the storage, administration and recording of medicines.

Medicines were generally stored securely and at appropriate temperatures, although we found the seals on the emergency medication storage boxes at South Bank Practice were not tamperproof and could easily be removed.

Staff regularly checked the stock levels and expiry dates for medicines, including emergency medicines and vaccines.

Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments. Liquid nitrogen used for cryotherapy (treatment using low temperature) was also stored as per best practice and national guidelines.

Patient Group Directions (written instructions allowing non-prescribing health professionals to administer specified medicines to a specific group of patients without a specific prescription) were in place and up to date.

Patient Specific Directions (a formal written instruction provided by a prescriber, detailing the medicines to be supplied and/or administered to a specific patient) were also in place and had been completed as per best practice.

There was a programme of regular clinical audits of prescribing that focused on improving care and treatment. These included monthly audits of patients prescribed valproate medicines (a drug associated with a high risk of serious harm to unborn babies if taken during pregnancy and fertility issues in males); audits of transgender patients to monitor cervical screening uptake; and audits of patients prescribed hydroxychloroquine (a medicine used to treat long-term inflammatory disorders of the joints or skin which can cause damage to the eyes and potential loss of vision if used long-term).

They also included monthly audits of two-week wait cancer referrals and if a referral was identified as missing or incomplete, the responsible GP was tasked to action the referral promptly.

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 below the national average.