Westbury 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 has changed to requires improvement.

The service was in breach of legal regulation in relation to safe care and treatment

This service scored 44 (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 did not always have a proactive and positive culture of safety based on openness and honesty. They did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

The complaint procedure displayed in the reception area was out of date, did not include timescales for investigation of complaints and did not detail escalation routes should a person not be happy with the outcome or management of their complaint. Informal complaints were not logged to help identify common themes and trends.

Central incident and complaint logs were not maintained to ensure outcomes were tracked, and improvements embedded. It was reported that there had been 2 significant events and 1 complaint in the previous 12 months. Records did not detail reflection and learning to improve care. An event relating to a power outage that resulted in loss of power, heating and telephones was not available during the site visit and Care Quality Commission (CQC) had not been notified, as required. The service failed to maintain an up to date and effective system for recording dispensing incidents, including errors and near misses.

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. Referrals were managed in a timely way and test results were processed by the duty doctor at the end of each working day.

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. Clinical staff we spoke with were able to share examples of safeguarding concerns and the action taken.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. The practice maintained a list of vulnerable people.

The practice told us they acted on safeguarding concerns working in partnership with other organisations. They liaised with the local authority to ensure their safeguarding lists were up to date. However, we found alerts were not routinely added to co-habitants’ electronic records of children on the safeguarding register to alert staff of all people living within the same household. Leaders told us staff knew their patients and any locum staff were made aware of vulnerable patients.

The service did not always work well with people to understand and manage risks. They did not always provide 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 but not monitored effectively to ensure it was safe to use. Defibrillator patches were out of date despite the checklist being marked as completed. Multiple oxygen tubings were out of date. This meant staff could have used out-of-date equipment in an emergency, which could compromise patient outcomes.

Staff could recognise a deteriorating patient and knew of the action to take.

The premises were leased from a landlord. The practice had a designated member of staff responsible for health and safety in addition to a written policy dated 2020.

The service did not always detect and control potential risks in the care environment. We found not all environment risks had been identified or actioned, for example trip hazards due to the worn and uneven carpets. The door to the dispensing area/office was wedged open, which posed a fire safety risk in addition to a security risk for medicines. The environment was found untidy and cluttered potentially posing a fire risk.

Not all records to evidence maintenance and service checks had been carried out or risk assessments were available on the day of the site visit. Some records were later shared with us. Areas of the practice looked tired and were not well maintained, for example broken cupboard doors were seen in 1 clinical room. In addition, not all cleaning products were safely stored.

An emergency contingency plan had been developed, implemented and shared with the practice team in advance of a severe weather warning in January 2026 to ensure continuity of the service.

The service had experienced staff changes in the previous 12 months. Staff felt the team would benefit from more clinical staff such as health care assistants.

There were a range of clinical and non-clinical roles within the practice. Leaders told us the practice encouraged and paid for staff to attend any training they wanted to attend as long as they cascaded the learning to staff. They also said they were trying to have peer review and discuss clinical cases. The practice told us they directly employed a clinical pharmacist from the Primary Care Network (PCN) 1 session a week. Their competency was only audited by the PCN against work done whilst employed by them and not by the practice. Leaders told us they met with the clinical pharmacist once a month to discuss their work with patients.

Staff told us they received support and development opportunities. Although not all staff felt they had received enough specific training for their role. We found training was not up to date, learning needs and development of staff was not always managed appropriately. The team completion rate for essential training at the time of our site visit was 59%.

There was no documented evidence of completed induction for new staff employed on the staff records sampled. Safe recruitment practices were not followed. For example, no proof of staff identity, qualifications, checks with professional bodies where relevant or references were available on the staff files sampled.

The service did not assess or manage the risk of infection. They did not detect and control the risk of it spreading.

The practice had a designated infection, prevention and control (IPC) lead but not all staff had received IPC training and the IPC policy did not meet the required guidance. The IPC audit completed in May 2025 failed to identify all risks. In particular, carpets, curtains and other soft furnishings had not been risk assessed or included in a cleaning schedule. Cleaning schedules did not include specific tasks and frequency including deep cleaning of carpeted areas. The cleaning contractors had left the practice in November 2025, and staff were required to clean but were unfamiliar with the standardised systems. The environment was found generally untidy and cluttered making it difficult to clean. Not all cleaning products were safely secured, and not all staff were familiar with safety data sheets or procedures in relation to the control of substances hazardous to health. The hand gel held in the reception area was clogged and therefore not readily accessible to help mitigate the risk of cross infection

The service did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

Medicines at the practice were not stored securely. We found evidence of poor stock management within the dispensary. Shelves contained several out-of-date medicines, and some medicines were not in boxes and lacked batch numbers and expiry dates. This meant we could not be assured that certain medicines supplied to patients were always safe to use.

The practice managed prescription stationery securely, and paper prescriptions were tracked safely within the building.

Controlled drugs (CDs) were not managed safely. Several CDs that were stored in the CD cupboard had not been recorded correctly in the register. Leaders and staff were unable to explain why these discrepancies existed. CDs returned by patients for destruction were being kept in a filing cabinet rather than in the locked CD cupboard, which did not comply with legal storage requirements. These CDs were moved on the day of the inspection for safe storage. We identified multiple issues with the CD register. Stock balance checks were not being completed in line with national guidance, medicines had not been transferred into the current register and entries were crossed out rather than corrected following legal requirements. Staff were unaware that different brands of CDs must be recorded separately, and some entries had been made into the wrong registers. Staff had not opened or closed its registers correctly, and invoices had been shredded rather than retained, which did not meet legal record-keeping requirements. The lead GP began correcting these issues when they were raised during inspection.

We found concerns regarding vaccine storage. The practice could not demonstrate that staff consistently checked their dataloggers in fridges. Manual fridge temperature checks were not recorded on days when staff members who recorded temperatures were absent. As a result, we could not be assured that vaccines had been stored within the required temperature range to remain safe and effective.

Essential emergency medicines and equipment were in place; however, several items of emergency equipment were out of date, despite date-checking lists suggesting they had been reviewed. This meant there was a risk that staff might use unsafe or ineffective equipment in a medical emergency.

The practice did not have an up-to-date or effective process for recording dispensing errors. The error log had not been updated for more than a year, and a recent error brought to our attention had not been recorded at all. This poses a risk that the practice was not learning from mistakes or taking steps to prevent similar incidents from recurring.

Governance arrangements for medicines management were weak. Leaders and staff were not familiar with the required processes for managing national safety alerts or for overseeing Patient Group Directions (PGDs). Only one section of a signed PGD was available on the day of inspection. The practice could not provide evidence that medicine recalls had been acted on. This lack of oversight meant the practice had no assurance that important medicine-related safety information had been followed.

As part of the inspection, a GP specialist adviser (SpA) carried out remote searches of clinical records. For patients on Direct Oral Anticoagulants (DOACs), creatinine clearance was often missing or overdue: 50 of 114 patients lacked any record, and 84 lacked renal calculations within 12 months, increasing the risk of incorrect dosing. The Lead GP informed us in interview that the clinical pharmacist had been employed for an extra session to work their way through these and confirmed that by the end of March all patients had been contacted and asked to arrange for testing and those who responded had their creatinine clearance score completed. Searches also identified weaknesses in the diagnosis and management of diabetes. Of 10 potential cases, our searches confirmed 6 missed diagnoses and 3 patients managed inappropriately, indicating unreliable systems for timely identification and follow up. Among high risk diabetes patients, 2 of 5 had no review after raised blood sugar results. The lead GP informed us repeated efforts had been made to contact patients with raised HbA1c and that the patients had declined to be seen and they had not exempted the patients in order to give them a chance to participate and repeat contact made. Medication reviews checked during searches lacked adequate documentation, with no clear evidence that full reviews were being completed, limiting assurance of safe medicine reviews.