Somerford Grove 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 69 (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 demonstrated a proactive and positive safety culture founded on openness and honesty. Staff described an environment where concerns were raised and discussed openly, supported by daily after-surgery meetings that provided opportunities to review patients, safety concerns and operational issues. Learning was shared through regular educational sessions, including weekly teaching meetings before clinics and protected learning opportunities with local partners. The provider showed how learning from system changes introduced by the Integrated Care Board was communicated to staff to support consistent implementation and safe patient care. Staff said they felt supported to raise uncertainties and seek advice from colleagues. Managers encouraged staff to speak up when things went wrong. Clinical issues were discussed at staff meetings, enabling the whole team to reflect and learn together. Staff consistently described an open culture where safety was a clear priority. Effective processes were in place for reporting incidents, near misses and safety events, alongside systems for recording and investigating complaints. When things went wrong, staff apologised, offered appropriate support to those affected and used learning from incidents and complaints to make improvements that enhanced care for others. The practice demonstrated a proactive and positive safety culture founded on openness and honesty. Staff described an environment where concerns were raised and discussed openly, supported by daily after-surgery meetings that provided opportunities to review patients, safety concerns and operational issues. Learning was shared through regular educational sessions, including weekly teaching meetings before clinics and protected learning opportunities with local partners. The provider showed how learning from system changes introduced by the Integrated Care Board was communicated to staff to support consistent implementation and safe patient care. Staff said they felt supported to raise uncertainties and seek advice from colleagues.Managers encouraged staff to speak up when things went wrong. Clinical issues were discussed at staff meetings, enabling the whole team to reflect and learn together. Staff consistently described an open culture where safety was a clear priority. Effective processes were in place for reporting incidents, near misses and safety events, alongside systems for recording and investigating complaints. When things went wrong, staff apologised, offered appropriate support to those affected and used learning from incidents and complaints to make improvements that enhanced care for others.

The practice worked with people and healthcare partners to establish and maintain safe systems of care. There were arrangements to support continuity of care when patients moved between services and when referrals to community and secondary care providers were required. Staff worked closely with multidisciplinary teams, health visitors, midwives, mental health services and Primary Care Network colleagues to coordinate care. Referral processes were supported by clinical systems and oversight arrangements.

The practice had systems to ensure test results were reviewed and acted upon appropriately. Results were received into a shared inbox where administrative staff allocated results to the requesting clinician. Urgent results were directed to the duty doctor system to ensure timely review and action. Daily clinical discussions and multidisciplinary working supported the sharing of relevant information across teams and services. The practice operated a triage system supported by duty doctors available each morning and afternoon to ensure urgent concerns were identified and managed promptly.

The practice worked with people and healthcare partners to understand what being safe meant to them and how best to achieve this. There were identified safeguarding leads for both children and adults who provided oversight and support. The practice worked with local safeguarding systems through regular liaison with partner agencies including health visitors and community services. Processes were in place to identify vulnerable patients, share concerns appropriately and respond to safeguarding information received from external agencies. Safeguarding responsibilities were clearly understood by staff. The practice shared concerns quickly and appropriately.

Safeguarding policies were in place and known to staff. The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations.

The practice worked with people to understand and manage risks by thinking holistically. There was a robust triage system supported by two duty GPs available during both morning and afternoon sessions to review urgent concerns and deteriorating patients. Emergency equipment was available and properly maintained. Staff were trained to recognise signs of deterioration, including sepsis, and understood when escalation was required. Patients were advised about risks related to their condition and were given guidance on what to do if their condition worsened.

The practice detected and controlled potential risks in the care environment. However, we identified that there was no signed record to demonstrate that cleaning tasks had been completed each day. On the day of our on-site visit the premises were visibly clean and well maintained. Leaders acknowledged this gap and confirmed action would be taken to introduce a documented cleaning checklist for staff. Aside from this issue, environmental risks were managed appropriately and there were systems to support the delivery of safe care.

Contracts were in place to ensure the premises were maintained. Health and safety risk assessments and audits had been undertaken and risks identified had been addressed. Staff were aware of the practice’s business continuity plan which was regularly reviewed and monitored to ensure the service remained prepared for potential disruptions.

The practice made sure there were enough qualified, skilled and experienced staff who received effective support, supervision and development. The staffing model included a range of clinical and non-clinical roles, including GPs, nurses, pharmacists, pharmacy technicians, paramedics, social prescribers and mental health professionals. Staff benefited from daily clinical meetings, weekly educational sessions and pharmacist training. Leaders promoted a supportive culture and staff reported they could seek advice when required. Systems were in place to support staff working within their competencies and to maintain professional development.

The practice assessed and managed the risk of infection. Infection prevention and control arrangements were in place and environmental risks were generally managed.

The practice had a designated infection prevention and control lead and all staff had relevant training. Risk assessments and audits were completed, and actions taken to mitigate risks.

The practice had policies, clinical meetings, pharmacy support and systems to oversee prescribing, high‑risk medicines and safety alerts. Leaders described how they monitored patients’ health, including those prescribed medicines such as warfarin, methotrexate and lithium. Staff demonstrated good knowledge of relevant best practice and professional guidance, and non‑clinical prescribers were supported through competency assessment and clinical supervision.

A CQC GP specialist adviser reviewed agreed clinical searches to assess whether medicines monitoring was effective.

These searches identified gaps in oversight. One patient prescribed an ACE inhibitor or angiotensin receptor blocker required review and updated blood tests. Four patients prescribed mirabegron required blood‑pressure monitoring to ensure ongoing prescribing remained appropriate. Five patients prescribed NSAIDs or antiplatelet medicines required review to clarify whether gastroprotection was indicated and documented. The practice reviewed these cases during the assessment and took action; however, residual risk remained because monitoring had not been consistently completed at the required intervals.

Other searches, including those relating to azathioprine monitoring, diabetes reviews, asthma reviews and routine medication reviews, found appropriate management and follow‑up.

The practice had systems for responding to medicines safety alerts through online tools and the pharmacy team. Staff reviewed alerts and took action where required. Published prescribing data for April 2025 to March 2026 showed generally positive prescribing performance, including lower‑than‑expected antibacterial prescribing (0.61 items per STAR‑PU compared with an expected 0.76) and reduced use of broad‑spectrum antibiotics. Local audit activity also demonstrated a reduction in co‑amoxiclav prescribing over the previous six months.

Otherauditactivity,includingantimicrobialstewardship,structuredmedicationreviewsandoptimisationofSGLT2inhibitorprescribing,demonstratedappropriateactionandcontributedtosaferandmoreeffectivemedicinesuse.

While these strengths demonstrated effective elements of medicines optimisation, the gaps identified through clinical searches showed that monitoring systems were not always fully effective.