Wychbury Medical Group

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 72 (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.

Staff we interviewed during the CQC assessment demonstrated clear awareness of the significant event process and confirmed that learning points were either shared across the service with the relevant staff involved or staff had access to minutes for learning. Of the 70 staff who responded to our CQC feedback questionnaires, the majority, including clinical and non-clinical team members, showed strong understanding of the process and learning, including its role in continuous improvement.

We found that appropriate significant event analysis and organisational learning took place during monthly practice meetings. The service’s significant event analysis (SEA) process included root cause analysis, and an annual thematic review to identify any recurring themes or trends.

An annual review of SEA’s was undertaken across 2024 and 2025. A total of 21 SEAs were recorded. These were categorised by severity, with 4 classified as minor, 14 as moderate, and 3 as major. The annual review confirmed that no recurrent themes were identified.

Staff felt supported to raise concerns, and managers actively encouraged openness when issues arose. During staff meetings, the teams discussed and learnt from clinical and non-clinical issues. Staff felt there was an open culture, and that safety was a top priority. 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.

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.

Systems were in place to process information for new patients. We reviewed the daily task flow and noted a high volume of tasks. Our sample confirmed these had clinical oversight; however, given the large workforce, we discussed whether a process could be embedded to ensure tasks were removed once actioned. After the assessment, the provider informed us they had strengthened their monitoring process to ensure timely removal of completed tasks and appropriate follow-up where required.

We found systems were in place to ensure referrals and test results were managed in a timely way. For example, there was an embedded alert process for two week wait referrals, in addition to weekly auditing undertaken to act as an additional safety net to confirm that all referrals had been appropriately actioned.

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, for example, people on the practice palliative care register.

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 a range of structured meetings in place. These included safeguarding, multi-disciplinary, educational events, clinical meetings 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 policies were in place and well understood by staff. All staff working in the practice had received appropriate training in safeguarding procedures relevant for their role. The practice maintained an up-to-date register of vulnerable individuals and acted promptly on concerns, working in partnership with external organisations such as school nurses, health visitors, and social prescribers.

Safeguarding registers were regularly reviewed to ensure accuracy. The practice had nominated safeguarding leads supported by administrative staff, and patient records included current read codes with alerts to highlight safeguarding concerns.

Multi-disciplinary team meetings were held to discuss vulnerable patients, including children on the safeguarding register, as well as those requiring palliative or end of life care. In September 2025, the practice delivered a staff wide education event on safeguarding, aligned with its ‘was not brought’ policy.

Each site displayed a safeguarding board ensuring staff were equipped to respond effectively to concerns.

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 at all sites, for example oxygen and the Automated External Defibrillator (AED).

Staff demonstrated understanding of emergency protocols, and all staff were trained in basic life support. 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.

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.

Health and safety related policies and procedures to manage health and safety were in place. We found risk assessments were completed in October 2025. This was reviewed to monitor the premises to mitigate risks. Fire safety policies were in place and staff were aware of how to access these. Fire marshals had undertaken additional training for the role. Systems were in place for the regular checks of fire alarms, extinguishers and fire evacuation procedures. Contracts were in place to ensure the premises were clean. Clear signage around the building supported people and staff in the event of an emergency evacuation.

Regular monitoring was in place to ensure guidelines were adhered to and all staff had been made aware of the appropriate procedures to follow.

Staff had been provided with training in health and safety related topics such as fire safety, infection control, basic life support and resuscitation training. Staff feedback indicated that all respondents were confident in the health and safety arrangements currently in place; however, some comments suggested that certain sites could benefit from infrastructure upgrades.

During the site visit, some areas of the premises were identified as requiring further improvement. Feedback was provided and immediate remedial action was taken where necessary. For example, emergency pull cords were missing from disabled toilets across all sites; this was escalated to on‑site staff, and leaders confirmed to the CQC that corrective works were actioned the same day, with evidence supplied after the inspection this had been completed.

At Chapel House Surgery, disabled toilet access was limited, and the reception layout presented challenges for wheelchair users and those with prams. In addition, the medicine fridge plug was not clearly marked to prevent accidental disconnection. At Cradley Road Medical Centre, a recommendation was made to strengthen security by routinely changing key codes, which the provider agreed to review in line with premise security protocols. Following our discussion the provider confirmed they had already identified upgrades for Chapel House Surgery. Evidence provided demonstrated that plans for improvement were well advanced, with architect’s drawings and building quotations shared with CQC for works to replace the kitchen area and disabled toilet. In addition, the provider submitted evidence confirming that remedial actions identified had been taken, including clear labelling of the medicine fridge plug and reconfiguration of the reception area at Chapel House Surgery to improve accessibility.

The provider demonstrated effective detection and control of environmental risks, ensuring that equipment, facilities, and technology supported the safe delivery of care.

The service made sure there were always enough qualified, skilled and experienced staff, who received thorough support, supervision and strong development opportunities. They worked together well to provide safe care that met people’s individual needs and teamwork across the organisation was strong.

Staffing and workforce planning were jointly led by a GP and the practice manager. Protected time was allocated for discussions and decision making relating to workforce, recruitment, and service delivery, with outcomes reviewed at partner and management meetings. The practice employed a dedicated human resources (HR) staff member to ensure appropriate guidance and processes were consistently in place. We spoke to the HR lead who assured us of the safe recruitment processes and sickness policies in place to support staff. Exit questionnaires were carried out for departing employees and feedback shared with leaders to inform improvements in recruitment and retention strategies. The provider utilised external HR software to manage all aspects of employee health and safety, ensuring compliance and effective oversight. In addition, a range of designated lead roles were established to strengthen governance and service delivery. These included wellbeing lead, premises lead, finance lead, digital lead, Caldicott Guardian, operations manager, and IT/data coordinator.

Rotas were planned in advance to enable effective cover arrangements, and all reception staff were trained to work across sites, ensuring continuity of service during periods of absence or increased demand. Over the past 2 years, the practice had expanded its workforce to meet growing patient demand, including an increase in GP sessions from 85 to 96. Two additional staff had been employed on a temporary basis to provide additional flexibility and maintain safe staffing levels during annual leave, sickness, or unexpected workload pressures.

The practice employed a range of clinical and non-clinical staff. Training opportunities were available online and through both internal and external face to face sessions. A skills matrix was maintained to support competency management, and staff with extended roles had completed additional training. Mandatory training compliance was closely monitored, with the majority of the 98 staff members having completed all required modules. All staff had undertaken Tier 1 learning disability and autism training, while some clinical staff had completed Tier 2. The provider confirmed that Tier 2 training for the remaining staff was being rolled out in stages to ensure adequate service cover was maintained.

A role specific induction policy was in place for new staff members. We spoke to both clinical and non clinical staff who described the induction process as comprehensive and supportive, incorporating shadowing opportunities, dedicated sessions with management, HR, infection control lead, clinical observations and buddying. Staged competencies sign off were in place at 8 weeks, 12 weeks, and 6 months. Learning needs and other areas of staff development were managed effectively, with competencies reviewed through appraisals, clinical supervision, audits and monthly monitoring.

Robust processes were in place to ensure clinical oversight and competency, with lead roles such as clinical lead, prescribing lead and a nurse clinical lead. These included GP supervision, home visiting supervision, mentoring meetings, supervision logs, case discussions, competency spot checks and clinical audits. A GP lead had oversight for the allied healthcare team, with quarterly spot checks and clinical support slots throughout the day. Clinical audits were undertaken by senior partners on a rotational basis. Each audit followed a structured seven-point strategies, providing opportunities for reflection and enabling the identification of areas requiring improvement. Processes were in place to ensure the safe and effective review of results. Registrars working within the practice were allocated a limited number of results, with blood tests assigned according to staff training and competence. Spot checks were undertaken by the clinical lead GP every three weeks to confirm that pathways were being appropriately followed.

Nurse meetings were held monthly and incorporated education sessions, case discussions, supervision, audits, and clinical updates, supporting continuous professional development and maintaining high standards of clinical practice. Staff told us that meetings were scheduled on different days to ensure part-time staff had the opportunity to attend. Topics covered included diabetes, respiratory, nutrition, conflict resolution, attention deficit hyperactivity disorder (ADHD) and autism.

Safe recruitment practices were consistently followed, as confirmed by a review of personnel files. Records of staff immunisation status were maintained, or risk assessments completed where appropriate. All staff had received annual appraisals.

Staff feedback was positive. Of the 70 staff who responded to the CQC feedback questionnaires and those we spoke with during the assessment, 94% reported that staffing levels were sufficient to meet service demand, 100% reported that they had received enough specific training for their role and 100% stated that managers were mostly visible and approachable.

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.

The practice had a designated infection, prevention and control lead (IPC) and all staff had had relevant training. All new staff members were required to complete training with the IPC lead as part of their staff induction. The latest audits for all sites were completed in January 2025 and had achieved 89.6%. Quarterly audits and spot checks were completed to monitor that processes were being followed and to reduce the risk of the spread of infection. Risk assessments and action plans were completed to mitigate risks. For example, the replacement of dressing trolleys, worktops and chairs. Cleaning schedules were in place and followed. During our assessment the service was acutely aware of the need for some refurbishment at some of the sites we visited but all were visibly clean and tidy.

Infection prevention and control policies were in place and accessible to staff who were familiar with the required actions, including the management of sharps injuries and safe handling of clinical specimens.

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.

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. Staff followed protocols to ensure they prescribed all medicines safely, and ensured people received all recommended medicines reviews and monitoring.

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. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments.

The service had systems to manage and respond to safety alerts and medicine recalls, however we found that some areas required strengthening. For example:

Clinical searches identified 120 patients prescribed disease‑modifying antirheumatic drugs (DMARDs) for the treatment of autoimmune conditions. Of these, 5 patients (4.1%) had not received the required monitoring within the last 12 weeks. We sampled 5 patient records, and all included the day of the week for medicine administration. However, inconsistencies were noted in the monitoring of liver function tests, urea and electrolytes, and full blood counts. While some patients had completed elements of the required monitoring, this was not consistently applied across all tests. We found for some patient’s alerts were not in place to identify when monitoring was overdue. This was discussed with the provider, who agreed to investigate the issue further. The provider subsequently rectified the alert system to ensure overdue monitoring could be identified and addressed promptly.

Systems were in place to manage and respond to safety alerts. However, our clinical searches identified patients aged 75 years and above who were on medicines called Direct oral anticoagulants (DOACs) which are used to help prevent blood clots from forming was not always at the frequency required for frail people or those aged over 75 years. We discussed the frequency of monitoring with this specific cohort with the provider who agreed to take action.

The provider was able to demonstrate they had some processes in place in relation to safety alerts issued by the Medicines and Healthcare products Regulatory Agency (MHRA), however further strengthening was required to ensure all alerts were acted on. For example, we reviewed a safety alert concerning people 65 years and above who were on medicines call citalopram/escitalopram, used in the treatment of depression. We found there was 23 patients prescribed this medication that carries a risk of ventricular arrhythmia as a potentially fatal side effect. A review of 3 patient records confirmed that, although medication reviews had been undertaken, there was no documented evidence of electrocardiogram (ECG) monitoring or that patients had been informed of the associated risks.

Following our clinical review the provider took immediate action to address the areas identified during our assessment and provided assurances this had been strengthened.

Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes. For example, the number of antimicrobials issued by the practice were in line with national averages. There were regular clinical audits of prescribing that focused on improving care and treatment.