Linkway Medical 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 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.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. Representatives from the Patient Participation Group (PPG) felt the provider took concerns seriously and proactively made improvements to the service. Managers encouraged staff to raise concerns when things went wrong. The provider had processes for staff to report incidents, near misses and safety events. The practice had a significant events policy, and a reporting form was in place, which was accessible to all staff members. Staff felt there was an open culture, and that safety was a top priority.

Weekly practice meetings were in place to ensure staff were kept updated. During these meetings there were a set agenda of topics for discussion. This included safeguarding concerns and recent death notifications to support staff if they had conversations with family members.

The practice had a procedure in place to ensure any information received concerning attempted suicide was shared with the on call GP and lessons learned were shared in the weekly meetings to provide staff with the guidance and information needed and to provide support to patients.

GP registrars working at the practice presented the audits they had completed at the practice weekly meetings. These provided information on what they had learnt and also identified any areas for improvement. For example an audit had been completed on HIV Cholesterol medication. The results of the audit were discussed with the practice team. Nine patients were identified through the audit that required further review. The GP registrars were discussing these patients with the hospital consultants.

The practice leadership team organised regularly training updates. These included IRIS training to support staff in providing the appropriate care for patients suffering from domestic abuse. Other training had been organised with a range of community teams. For example, heart failure nurses and the local musculoskeletal (MSK) team

There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Information reviewed demonstrated that people had opportunities to provide feedback, and they knew how to make a complaint. Lessons were learnt from individual complaints and shared with the practice team to improve the quality of care. Feedback and information were available in the practice and on their website.

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.

Effective systems were in place for processing information relating to new people including the summarising of new records. The service worked with other providers to deliver shared care and when patients moved between services. We found clinicians made appropriate and timely referrals in line with protocols and up to date evidence-based guidance. This was supported by a system in place to ensure all patient information including laboratory test results and referrals were reviewed and actioned in a timely manner.

The provider told us that there were processes in place that were monitored and managed to keep people safe. For example, 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.

There were a range of structured meetings in place. These included safeguarding, multi-disciplinary and practice team meetings. Weekly team meetings were held for all staff to have the opportunity to discuss any concerns, and the leadership team had the opportunity to discuss and share learning from incidents and complaints.

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, who were appropriately trained in safeguarding procedures. The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations.

There was a safeguarding lead for children and adults, and all staff were aware of who to speak to if they identified a safeguarding concern. The practice had volunteered to take part in a domestic abuse audit with 7 other GP practices in the Sandwell area. The local safeguarding team reviewed a random sample of 5 patient records and found domestic abuse was clearly documented, indicating a 100% compliance rate with established protocols. A review of each record demonstrated that disclosures of domestic abuse were documented appropriately and in line with best practice guidelines.

The practice had dedicated learning disability and mental health sessions on a weekly basis, which were accessible by all clinicians to book patients into who required further review and support.

The practice had developed an under 16 did not attend (DNA) work list, to identify patients who failed to attend a hospital appointment. This was monitored by administration staff to ensure follow up appointments were highlighted and where necessary discussed with a GP if further action was required.

There were processes in place to follow up children and young people who were not brought to their appointments with the provider and for secondary care appointments. A safeguarding report was run on a monthly basis to ensure the information stored by the practice was regularly reviewed and updated.

Practice meetings were held every week, and safeguarding was a standing agenda item. Community teams were invited, and information was shared appropriately for the care of people with safeguarding and vulnerable concerns. For adult patients weekly multi-disciplinary team meetings were held with community teams.

There was a policy in place for the renewal of DBS checks. Records we examined showed that staff had a DBS check in place. DBS checks identify 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.

All staff were trained in basic life support and staff could recognise a deteriorating patient. Staff were aware of what actions they would take if they had a deteriorating patient, however we found no staff had completed sepsis awareness training. Following the onsite assessment, we received assurances that all staff had completed the relevant training. Patients were advised on risks related to their condition and actions to take if their condition deteriorated. Emergency equipment was available and maintained.

Leaders told us that they worked with services locally to understand and manage risks. The practice also had registers in place to support those patients who were vulnerable or who had mobility or communication needs.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Health and safety related assessments and procedures to manage health and safety were in place. A health and safety risk assessment and fire risk assessment had been completed. Regular monitoring was in place to ensure guidelines were adhered to and all staff had been made aware of the appropriate procedures to follow.

We found staff had been provided with training in health and safety related topics such as fire safety, infection control, basic life support and resuscitation training, however some staff required updates. Staff reported during discussions that they had no concerns regarding the arrangements in place to ensure health and safety.

There were policies and procedures in place for the management of health and safety. 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 with weekly checks carried out around the building.

The practice had completed assessments in place for the control of hazardous substances. Evidence provided by the practice showed equipment was regularly calibrated and electrical items were PAT (portable appliance testing) tested. Evidence provided showed the last testing had been completed in January 2026.

There was a business continuity plan in place which was monitored and reviewed.

During our site visit we found the premises were well maintained. The provider detected and controlled potential risks in the environment. They made sure equipment, facilities and technology supported the delivery of safe care. Regular checks were carried out on the premises, facilities and the equipment provided. Contracts were in place to ensure the premises were clean and well maintained. Clear signage around the building supported people and staff in the event of an emergency evacuation.

The service did not always 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 always work together well to provide safe care that met people’s individual needs. The clinical leadership team told us they had systems in place for the monitoring of staff, which included regular conversations as part of their clinical supervision, we were told that regular meetings were held as part of clinical supervision and continued professional development. For registrars and medical trainees slots were allocated on the appointment system for discussions about patients as part of their learning.

We identified gaps in training, for example, health and safety, sepsis awareness, fire safety and confidentiality. We received assurances from the leadership team that staff were in the process of updating their training following the onsite assessment. Staff development was managed appropriately and staff were working within their agreed areas of competence.

The practice had recruitment policies in place, and all staff had completed disclosure and barring checks. All newly employed staff had completed an induction to ensure they were competent in carrying out their role. We reviewed 5 personnel files and found appropriate checks such as previous employment record, immunisation status and proof of identity checks had been completed for 4 out of the 5 records we viewed. An up-to-date record of the professional registration of one of the clinical team was not available. Personnel folders were well organised and there was a systematic approach to ensure that personnel folders were managed appropriately. Following the onsite assessment, we received assurances that the professional registration had been updated and a process had been put in place to ensure regular checks were completed.

There were a range of clinical and non-clinical roles within the practice and the practice was a training site for GP registrars and medical students. GP registrars are doctors who have completed medical school and the first years of their postgraduate training and are in the final stages of specialist GP training.

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.

An infection control audit had been completed to identify potential risks and take appropriate action where required. At the time of the onsite assessment, the audit provided to us had been completed in October 2025, and the practice had achieved 93% overall. The action plan had identified that there were no cleaning schedules in any of the clinical consultation rooms. At the time of the assessment, this action had been acted on, and cleaning schedules were in place in each clinical room and signed to confirm when cleaning had been completed.

The practice had a designated infection, prevention and control lead and all staff had completed training relevant to their role. Staff were aware of the systems and processes to follow to ensure clinical specimens were handled safely.

The practice had policies in place for infection, prevention and control which was accessible to staff and staff were aware of the action to take. For example, in the event of a sharps or contamination injury.

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 the assessment, we carried out remote clinical searches to review how patients’ medicines were monitored and if the appropriate care and treatment was being received. We reviewed patients who had been prescribed Aldosterone Antagonist medicines. Aldosterone Antagonist medicines are used in the treatment of high blood pressure and heart failure. The clinical search identified potentially 9 out of 61 patients on these types of medicines who had not had urea and electrolyte (UE) monitoring within the past 6 months. We reviewed the records of 5 patients and found 2 patients were overdue monitoring. Following the assessment, we received an action plan from the clinical team which showed 2 of the 9 patients had already booked a blood test. The other 7 patients identified had been contacted to ensure they received the appropriate follow up.

A second search was completed to review the number of patients over the age of 65 years who had been prescribed an NSAID without a proton pump inhibitor (PPI). Non-steroidal anti-inflammatory drugs (NSAIDs) are medicines that can help treat pain and reduce inflammation and a PPI are medicines that can support the reduction of gastrointestinal adverse effects when taking NSAIDs. The search identified 124 patients out of a total of 301 on an oral NSAID who had not been prescribed a PPI. We reviewed a random sample of 5 clinical records and found none of the patients had been prescribed the appropriate PPI protection. We discussed the findings with the clinical team and received assurances that all the patients identified would be reviewed.

We carried out a search to identify patients who had received a medication review in the past 3 months. The search identified 2517 patients. We reviewed a random sample of 5 records and found thorough medicine reviews had been completed by the GPs and clinical pharmacists.

The practice worked with the clinical pharmacists from the local Primary Care Network (PCN) to monitor people and the prescribing of medicines. All safety alerts were sent to the clinical pharmacists and leadership team to disseminate the information. The provider was unable to demonstrate they had processes in place in relation to safety alerts issued by the Medicines and Healthcare products Regulatory Agency (MHRA). For example, we carried out a clinical search to identify the number of patients on clopidogrel and either omeprazole or esomeprazole a PPI. Clopidogrel is an antiplatelet medicine. It prevents blood cells from sticking together and forming a dangerous blood clot. The search identified 13 patients on these medicines. We reviewed a random sample of 5 records and found all patients were on both medicines. The use of omeprazole/esomeprazole inhibits the effect of clopidogrel and should not be prescribed together.

There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.

Emergency medicines, vaccines and medical equipment had clear monitoring processes in place. There were appropriate arrangements in place for the management of vaccines and for maintaining the cold chain and a data logger was in place. We saw fridge temperatures were routinely monitored and vaccines reviewed at random were in date and stored appropriately. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments.

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 took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. Prescribing data reviewed as part of our assessment confirmed this. For example, the number of antimicrobials issued by the provider was in line with local and national averages.