Noakbridge 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

At our last assessment, we rated this key question as good. At this assessment, the rating remains the same.The service was in breach of legal regulation in relation to safe care and treatment. Not all medicines had been monitored and prescribed in line with national guidelines. The service had a good learning culture and people could raise concerns. Managers investigated incidents thoroughly. People were protected and kept safe. Staff understood risk, however there were gaps in processes to manage these risks. The facilities and equipment met the needs of people, an action plan was in progress to upgrade the interior and exterior of the building. There were enough staff, and staff had the right skills, qualifications and experience however not all staff had completed mandatory training in line with local policies and national guidelines. Managers made sure staff received protected time for training and regular appraisals to maintain high-quality care. Systems to ensure all prescribed medicines were being monitored in line with national guidelines required strengthening, improvements in infection prevention and control measures were required. Leaders had acted during the assessment to keep people safe and had started to embed quality improvement processes.

This service scored 66 (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 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. People felt supported to raise concerns and felt staff treatment them with compassion and understanding. The provider had processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Learning from incidents and complaints resulted in changes that improved care for others. During staff meetings, the team discussed and learnt from incidents and complaints. Lessons were learnt to continually identify and embed good practice. Staff felt there was an open culture, and that safety was a top priority.

The practice learned from external safety events and newly issued patient safety alerts. However, the mechanism in place to review active alerts required improvements.

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 when patients moved between services. Referrals and test results were managed in a timely way. Staff had a system in place to follow up urgent referrals where patients needed an appointment within two weeks.

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 policies were in place and known to staff, however during the assessment we identified that not all staff were trained to a level required for their role. The provider took immediate action to ensure staff had completed the required level of training. The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations. Feedback from people shared with us raised no safeguarding concerns.

The provider carried out staff checks at the time of recruitment and on an ongoing basis where appropriate/ Disclosure and Barring Service (DBS) checks were undertaken where required. (DBS checks identified whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable).

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. During the assessment the practice took immediate action to ensure portable suction equipment was available in line with national quality standards. Portable suction equipment is used to support airway clearance. Staff could recognise a deteriorating patient and knew of action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated. Staff we spoke with were able to describe the signs and symptoms for deteriorating patients or sepsis and staff had access to material to support them to identify emergency symptoms, however training records provided did not identify sepsis and recognising deteriorating patients training as required training for all staff, in particular receptionists. This was not in line with the Receptionist’s Handbook.

The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. Observations made during the inspection included difficulty for people who required reasonable adjustments to enter and exit the building. The practice leadership told us that funding to support improvements in the building to mitigate the risks had not been agreed with external stakeholders, however we did not seen evidence of a risk assessment, or details of the risks recorded on a risk register. The practice did not have a working closed circuit television system (CCTV) to support reception staff to monitor people who may require support to enter the building. Leaders shared a premises action plan, neither of these areas had been identified as actions for improvement. Contracts were in place to support with the premises being maintained. There was a business continuity plan in place which was monitored and reviewed.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked well together 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 mostly up to date, learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence. Safe recruitment practices were followed for staff employed directly by the service. However, not all staff had received training in recognising the symptoms of sepsis (a life-threatening illness caused by the body’s response to infection). In addition, not all staff had completed children safeguarding training appropriate to support them in their role. Leaders confirmed this had not been added to the mandatory training for those staff required to do the training and rectified this immediately.

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly. An infection prevention and control (IPC) audit had been carried out in April 2025, this identified areas of improvement, for example taps needed to be replaced to meet IPC standards and during the onsite inspection we noted patient and staff toilet taps were rusty. We observed flooring and sinks in some clinical areas needed replacing. Leaders shared timescales for this work to be completed by August 2025. At the time of the inspection the designated IPC lead had recently left the practice, leaders told us they had a plan to identify a new designated lead and support them with any required training to support the role. The practice had downloaded a generic IPC policy which had not been reviewed and updated to include practice specific information, for example the IPC lead within the policy had left the practice and the most recent lead contact had not been updated. Leaders shared partial evidence that the hand hygiene audit tool had been used to monitor compliance of good hand hygiene, this was not dated, and no timeframe identified for completion of identified actions. Cleaning schedules were in place and followed. Staff training records showed all staff had undertaken relevant training.

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

As part of our assessment, we interviewed the clinical lead GP. They were able to explain to us systems for appropriate and safe use of medicines, including medicines optimisation the practice had. However, the provider did not have effective systems to manage and respond to safety alerts and medicine recalls. Staff did not always follow established processes to ensure people prescribed medicines with specific risks received recommended monitoring. We carried out remote searches of clinical records as part of our assessment to check how the practice monitored patients’ health in relation to the use of high-risk medicines.

We found concerns regarding the prescribing of three medicines. Our clinical searches highlighted 9 patients prescribed methotrexate which is an immunosuppressant medicine. A sample of 5 of those patients showed they had the received the required monitoring, however the dose of medicine prescribed did not include the day of the week on which it was to be taken. British Rheumatology Society’s guidelines (2017), accredited by the National Institute for Health and Care Excellence (NICE) and the Medicine and Healthcare Products Regulatory Agency (MHRA) 2017 alert state this medicine should be prescribed to be taken once a week and should explicitly state which day of the week to be administered. This is to minimise the risk of overdosing which has the potential to lead to death.

Clinical searches identified 91 patients prescribed anticoagulant medicines to help prevent blood clots. We identified 45 patients had never had a weight check to ensure the correct dose was prescribed. In addition, we identified 81 patients were overdue their annual monitoring. We reviewed 5 records and found concerns with all 5 records. This meant the practice was not following the National Institute for Health and Care Excellence (NICE) guidance (updated July 2024). Under dosing leads to an increased risk of a blood clot/stroke, an overdose leads to an increased risk of severe bleeding.

Clinical searches identified 3 patients aged over 65 prescribed a high dose of medicine used for the treatment of mental health conditions. A safety alert in December 2014 reported the potential to cause an increased risk of dangerous heart rhythms. We reviewed all 3 records and found these patients had not received the required monitoring. During the inspection, the practice audited all patients prescribed the above three medicines and provided evidence that they had now carried out the correct interventions. The practice had also taken action to identify and learn from these findings and had raised an internal significant event.

Our clinical searches identified 1 patient with a potential missed diabetes diagnosis. The practice told us attempts had been made to contact the patient on multiple occasions. During our inspection the practice had commenced a medicine reduction plan to support engagement with the patient and safer prescribing.

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 received regular training, were competency assessed on medicines optimisation, and felt confident managing the storage, administration and recording of medicines.

Staff managed prescription stationery appropriately and securely. Nursing staff had the appropriate authorisations to administer medicines, including Patient Group Directions (PGD’s). We found one PGD in use included a member of staff who no longer worked at the practice and the PGD had not been updated to reflect this. During the inspection leaders told us they would take action to review their PGD’s processes.

Medicines were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines. Waste medicines were recorded and disposed of appropriately including medicines returned by patients. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments.

Staff took steps to ensure they prescribed medicines including antibiotics appropriately to optimise care outcomes. Prescribing data reviewed as part of our assessment confirmed this. For example, the number of antimicrobials issued by the provider was lower than local and national averages. Leaders shared examples of medicines audits of prescribing that focused on improving care and treatment, however we did not see examples of second cycle audits to demonstrate quality improvement.