The Armada Family 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 has changed from good to requires improvement.
The service was in breach of legal regulation in relation to staffing. The provider did not ensure staff were suitably trained, supported, and safely recruited.
 

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff understood how to raise concerns and report incidents. They were involved in the investigation process and in identifying learning. However, staff told us learning was not always shared with all staff, including those involved in the incident, and there was not always evidence learning from incidents had taken place. For example, an incident whereby a test result had been uploaded to an incorrect person’s record did not record any learning actions, despite the relevant policy (in relation to this incident) being updated and shared with the treatment room staff. Minutes from the clinical meeting around the same time also did not record any shared learning or advise a policy had been updated.
We viewed 2 other examples of learning events and found they did not thoroughly reflect the incidents that had occurred, learning was not clearly identified and any actions taken were not clear.
The service encouraged staff feedback, and each team had a communications book to provide feedback, raise any issues, or suggest ideas. However, staff were not always confident leaders would listen and take action. For example, we saw minutes from team meetings detailing suggestions from staff but for subsequent meetings, there was no evidence of any action taken. One example related to staff in the treatment room requesting a monthly meeting in April 2025, but meeting minutes from the next meeting in January 2026 showed that no action had been taken to review the number of meetings arranged.
 

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 people joining the service. The service worked with other providers to deliver shared care when people moved between services.
Referrals were managed in a timely way. For example, staff used a spreadsheet to monitor and ensure urgent referrals were managed effectively.
To ensure people were directed to the correct services or teams, staff used a system called Remedy (a clinical pathway and referral support platform used across Bristol, North Somerset, and South Gloucestershire). It provided up‑to‑date clinical pathways used to assess a person’s needs, referral guidelines, service information, and resources to support GP services and other healthcare professionals.
Staff supported people living in local care homes and provided regular visits. We were told by 1 of the care homes, ‘the practice always communicates effectively with the home, ensuring we are kept informed and supported.’
 

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 had safeguarding policies which were accessible to all staff. There was a process to keep people safe and safeguarded from abuse. Alerts on clinical records flagged people with safeguarding concerns.The service facilitated an all-ages multidisciplinary safeguarding meeting.
Staff knew who the safeguarding leads were, could explain the safeguarding processes and felt confident in raising concerns.
However, we reviewed staff training record and identified 33% of staff had an outstanding status for safeguarding children training and 26% for safeguarding adults training

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.
There were systems and processes to inform people of risks associated with their health conditions. However, these were not consistently effective.
Clinical searches undertaken during the inspection identified 132 people who may have a missed diagnosis of chronic kidney disease and had not been informed. A review of a sample of 5 people’s records confirmed all 5 had not been contacted by the service to inform them of this diagnosis. No evidence of harm to these people was noted. We raised this with the service leaders, who advised they would take action to follow up with those affected within a 2-week timeframe. To prevent this from occurring again, the service allocated additional time and resources to ensure people were identified and appropriately followed up.
However, emergency equipment was available and maintained. Staff could recognise a deteriorating person and knew of action to take. People were advised on risks related to their condition and actions to take if their condition deteriorated.
 

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.
The service was well maintained and free from clutter. The facilities and premises were appropriate for the services being delivered. We observed the service to be accessible and included space for wheelchairs and prams. Corridors and walkways were clear and free from hazards. Toilet facilities including baby changing facilities were available and hot water was a safe temperature.
Equipment, such as wheelchairs, were found to be maintained and within their service date range.
Electrical equipment was tested regularly to ensure it was safe to use, and equipment was calibrated for accuracy. The service had a health and safety policy, and contracts were in place to ensure the premises were maintained. Health and safety risk assessments had been completed.
The service had a fire procedure, and a fire risk assessment had been completed. Records showed fire alarms were routinely tested and there were trained fire wardens.
There was a business continuity plan in place which was monitored and reviewed.
 

The service did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.
The service had a recruitment policy, but it was not aligned with national legislation. As a result, information that must be obtained and retained for each person employed, such as confirmation of identity (including photographic identification), employment history, and criminal record checks where appropriate, was not always available.
We reviewed a sample of 4 staff files, 3 of which did not include appropriate references, and only 1 contained a risk assessment to mitigate the absence of references. In addition, evidence of checks on professional registrations for clinical staff was missing for 2 of the 3 files it was required for. Of the 4 files, 2 did not include their full employment history. Staff files did not also consistently contain evidence of routine vaccinations in line with national guidance, this was identified in 2 of the 4 staff files reviewed. The service showed us it had a risk assessment template to address gaps in information, but these were not always completed consistently to show what actions had been taken.
We reviewed staff training records for all staff and found there were gaps in completion. For example, out of a total number of 67 members of staff, 38 had not completed the appropriate level of training for learning disabilities and autistic people, and 15 staff did not have up to date training on the Mental Capacity Act 2005.
Staff did not always receive clinical supervision and an annual appraisal to ensure they were competent. In the sample of 4 staff files reviewed, 3 did not demonstrate staff had received clinical supervision and 2 did not demonstrate annual appraisal had taken place in line with the service policy. This was raised with the practice and leaders took immediate action and confirmed appraisals had been scheduled for all staff to take place within the following 2 months.
However, the service had a mixture of clinical and non-clinical staff to meet the requirements of the service. Staff were supported to develop their skills and take on new roles. For example, there were assistant managers who had been trained through an apprenticeship programme and a receptionist who had trained to be a phlebotomist.

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading. However, they did share concerns with appropriate agencies promptly.
The service’s infection prevention and control (IPC) policy stated an IPC audit tool would take place every 6 months, but the service was unable to provide evidence to show this had been completed.
During our onsite visit, we noted a number of issues that, had an audit been completed, would have been identified. For example, annual staff training for IPC was not up to date, with 11 staff members overdue their training. Although separate hand-hygiene audits had been completed, it was not clear from documentation that actions had been taken to ensure identified improvements were completed. However, the service had a designated IPC lead, who was new to the role. They were in the process of implementing new processes to manage IPC at the service.
Sharps bins used to dispose of used needles were safely used and disposed of, with weekly checks taking place. Personal protective equipment (PPE) was available to staff and in the event of a bodily fluid spills staff could access a spill kit. Treatment rooms were noted to be visibly clean and tidy during our onsite visit, containing the equipment required for staff to carry out their role.
 

The service did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.
We reviewed the service’s patient group directions (a legally recognised written instruction that allows registered clinicians to supply and/or administer specified prescription only medicines to groups of patients without the need for an individual prescription (PGDs). Out of total of 4 PGDs reviewed, none had been appropriately authorised. This was fed back to the service on the day to action.
A review of medication reviews as part of our clinical searches showed that records were not completed to show what had been discussed with people.
For example, the searches identified that 1,341 medication reviews were undertaken in a 3 month period and a sample of 6 were reviewed. Out of 6 medication reviews reviewed, all 6 showed no evidence of discussions with people being held in line with national guidance. Following feedback, the service took action by discussing the findings at a team meeting and implemented a new policy which contained details about what to cover in medication reviews and how to document those discussions.
People who were prescribed medicines which required specific monitoring, such as blood tests prior to prescribing were not always monitored in line with guidance. For example, for people taking anticoagulant medicines, 46 people were identified as not having had their required monitoring. We reviewed 5 records and found 4 had not received their monitoring. The service immediately contacted all identified people and arranged to have their monitoring completed.
People who were prescribed medicines that may interact with each other were not always informed of the risks. For example, for those prescribed clopidogrel and omeprazole, 50 people were identified. We reviewed 5 records and found all 5 had not been informed of the risks. Following this, the service took immediate action to contact the people affected.
However, staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. For example, the number of antimicrobials issued at the service for urinary tract infections was lower than local and national averages. We saw also examples of clinical audits of prescribing, but where prescribing errors had been identified, it was not clear how this was followed up with the clinician. The service confirmed it would review how actions would be followed up and recorded.
Staff we spoke with were aware of their responsibilities to raise concerns about unusual prescribing and told us how they implemented a new process following concerns about the misuse of a medicine. The service carried out remote prescribing and there were processes to identify and verify the person. The service also had systems to manage and respond to safety alerts and medicine recalls.
Staff also felt confident managing the storage, administration and recording of medicines. Staff managed prescription stationery appropriately and securely. Medicines were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, including vaccines. Emergency medicines were available and accessible to staff and were checked regularly. The emergency medicines held by the service were in line with national guidance. The service stored medical gases, such as oxygen, safely and completed safety risk assessments and regular checks on the amount in the cylinders. This was to ensure they would be safe to use and there were adequate supplies.