Clement Road 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 remains the same.

This service scored 75 (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.

Patients felt supported to raise concerns and felt staff treated them with compassion and understanding. The provider had processes for staff to report incidents, near misses and safety events and managers encouraged staff to raise concerns when things went wrong. The practice had a significant events policy which was accessible to all staff members. Staff felt there was an open culture, and that safety was a top priority.

Significant Event Analysis (SEA) processes were well embedded. Over the previous 12 months, 5 SEAs had been completed and reviewed. Staff we spoke with were aware of the reporting process and how incidents and events were discussed regularly to disseminate learning across the team and mitigate future risks.

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 lessons were learnt from individual complaints and shared with the practice team to improve the quality of care.

The practice carried out annual reviews of complaints and significant events to identify any recurring themes, trends, learning points, and opportunities for quality improvement. 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.

Effective systems were in place for processing information relating to new people including the summarising and coding of new records. The service worked with other providers to deliver shared care and when patients moved between services.

Systems were in place to ensure that all patient information, including laboratory test results and referrals, was reviewed and actioned in a timely manner. Referrals to specialist and urgent services, including two-week wait (2WW) referrals, were managed through a clearly defined process. The provider confirmed that these processes were monitored and there was a duty and buddy system in place to maintain patient safety. In addition, staff provided patients with appropriate safety netting advice regarding worsening or deteriorating symptoms.

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. There were a range of structured meetings in place. These included multi-disciplinary, governance, clinical 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 service shared concerns quickly and appropriately.

Safeguarding leads were in post and were known to staff. Safeguarding policies and procedures were in place and supported by information and guidance displayed throughout the practice. Staff had received appropriate safeguarding training and demonstrated an understanding of their responsibilities. The practice maintained a register of vulnerable individuals and held regular safeguarding meetings with multidisciplinary teams to promote effective communication, monitor concerns, and ensure appropriate action was taken when required.

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).

Staff demonstrated understanding of emergency protocols and had completed online training in basic life support. At the time of our assessment, the practice was in the process of arranging face-to-face basic life support training for staff. Receptionists were aware of actions to take if they encountered a deteriorating or acutely unwell patient and had been given guidance on identifying such patients. A duty doctor was available each day to support staff in prioritising patients who may need to be seen promptly. The practice also held registers to support patients who were vulnerable or who had mobility or communication needs.

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

Health and safety related assessments and procedures to manage health and safety were routinely reviewed and in place. Consultation rooms were available on the ground and first floor and routine maintenance such as lift servicing had been undertaken. Evidence provided by the practice showed equipment was regularly calibrated and electrical items were PAT tested (portable appliance testing). The latest calibration of equipment had been completed in September 2025. Legionella monitoring was in place.

Staff had been provided with training in health and safety related topics such as fire safety, infection control, basic life support and resuscitation training. Checks were carried out to the internal and external premises and feedback from staff reported they had no concerns regarding the arrangements in place to ensure health and safety.

Fire safety policies were in place, and a fire risk assessment had been completed in March 2026. Clear signage around the building supported people and staff in the event of an emergency evacuation. Premises security systems were in place and routinely monitored.

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. Staff knew when to notify a GP or other clinicians with concerns about a patient who may be acutely unwell and/or deteriorating.

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 oversight of allied healthcare staff and trainee doctors and systems in place for the monitoring of staff.

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 had been 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.

An infection control audit had been completed to identify potential risks and take appropriate action where required. At the time of the onsite assessment, the audit provided to us had been completed in June 2026, and the practice had achieved 99% overall.

The practice had a designated infection, prevention and control lead and all staff had completed training relevant to their role. Staff were aware of the systems and processes to follow to ensure clinical specimens were handled safely.

The environment was visibly clean, well maintained and appropriately equipped to support safe care. Clinical rooms were suitably stocked with essential equipment, including personal protective equipment (PPE), pedal bins and hand hygiene facilities. Cleaning arrangements were effective, with contracted cleaning staff in place. QR codes were displayed in clinical rooms to support monitoring and provide assurance that cleaning schedules were completed consistently.

The practice had policies in place for infection, prevention and control which was accessible to staff and staff were aware of the action to take. For example, in the event of a sharps or contamination injury.

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. As part of our assessment, we carried out remote searches of clinical records to check how the practice monitored patients’ health in relation to the use of high-risk medicines.

Clinical searches identified 17 patients prescribed disease‑modifying antirheumatic drugs (DMARDs) for the treatment of autoimmune conditions. We found that all of these patients had the required monitoring within the last 6 months.

A second search showed the number of people who had been prescribed medicines to reduce the risk of blood clots forming called direct oral anticoagulants (DOACs), who had not received the appropriate monitoring in the past 6 months. The search identified 123 patients on these medicines and 8 patients who were potentially overdue blood monitoring. We reviewed 5 clinical records and found they had all had renal monitoring in the last 10 months and 4 out of 5 people had been invited for blood monitoring.

We reviewed other areas of high-risk medicines that required regular monitoring which demonstrated high levels of compliance in place. For example, 99% of patients prescribed ACE inhibitors or angiotensin receptor blockers (ARBs), 92% of patients prescribed aldosterone antagonists for heart failure, and all patients prescribed lithium, amiodarone and warfarin had received the appropriate monitoring. Overall, medicines monitoring was well managed and demonstrated good oversight of patients prescribed higher-risk medicines.

We reviewed patients who had been prescribed more than 10 prescriptions for benzodiazepines or z-drugs in past 12 months (these are sedative medicines typically used to treat insomnia, anxiety or seizures). Our searches found there were 62 patients. We reviewed 5 patient records relating to the prescribing of Z-drugs for insomnia. 4 records showed patients had been advised of the risks of dependence within the previous 2 years; however, only 1 record evidenced consideration of dose reduction. We discussed this with the provider who told us they had an action plan in place to address the issues identified and strengthen the oversight and review of these medicines.

Our remote clinical searches found 370 patients had received a medication review in the previous 3 months. We reviewed a random sample of 5 clinical records from medicine reviews completed by either a GP or a nurse. While a review had been completed, it had not always been consistently undertaken for a number of multiple medications being used by each patient. We discussed the consistency of recording of this in patient records.

All safety alerts were sent to the lead GP to disseminate the information. The provider was able to demonstrate they had processes in place in relation to safety alerts issued by the Medicines and Healthcare products Regulatory Agency (MHRA). For example, we carried out a clinical search to identify women of childbearing age prescribed teratogenic drugs, medicines that had the potential to increase the risk of birth defects. The clinical search identified potentially 30 patients on this medicine. We reviewed 5 records and found 1 patient required an updated annual risk acknowledgement form and 1 had no documented advice on the risks. The practice confirmed after the assessment that appropriate action was taken to review these records. Other searches carried out in relation to safety alerts showed good compliance in place. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.

Emergency medicines, vaccines and medical equipment had clear monitoring processes in place. There were appropriate arrangements in place for the management of vaccines and for maintaining the cold chain. We saw fridge temperatures were routinely monitored and vaccines reviewed at random were in date and stored appropriately. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments.

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 and felt confident managing the storage, administration and recording of medicines. Staff managed prescription stationery appropriately and securely. Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics.