St Margaret's 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 75 (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. All staff including non-clinical were made aware of significant events. Weekly clinical meetings and monthly team meetings took place to discuss these matters, and the agenda and minutes were circulated to ensure all staff were kept informed, including those who were unable to attend.They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff gave an example of a significant event which had occurred recently noting that it prompted learning around recognition and management of a clinical issue. The event was documented comprehensively and dealt with efficiently. This had led to improvements in the service. Other significant events had been recorded in the same way.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. Representatives from the Patient Participation Group (PPG) reported the provider took concerns seriously and proactively made improvements to the service. Practice performance information was shared, particularly in relation to patient satisfaction, including survey results and Friends and Family Test feedback. Complaints, outcomes, and incidents were discussed where appropriate. The practice also involved the group in service improvements, such as changes to the premises and the introduction of total triage, with dedicated time at each meeting allocated to discuss ongoing developments.

Managers encouraged staff to raise concerns when things went wrong. During staff meetings, the whole team discussed and learnt from 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. Complaints were recorded consistently, with each entry including the date received, a description of the issue, and the actions taken.

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, with registration details capturing relevant health, lifestyle, screening, and family history information. The service worked with other providers to deliver shared care and when patients moved between services, including multidisciplinary working with district nurses and other professionals. Referrals and test results were managed in a timely way. A system was in place to support and monitor two‑week wait referrals, helping to ensure urgent referrals were processed and followed up in a timely way.

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. Staff described clear escalation pathways and were able to explain how concerns were raised with the relevant professionals depending on the situation. A safeguarding rota was in place, so reception staff shared responsibility for managing correspondence. Step‑by‑step written guidance was available to support staff within required timescales. The practice maintained a list of vulnerable people and carried out audits of the child protection register approximately every six months. They acted on concerns working in partnership with other organisations.

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. Equipment and medicines were stored in a central place which was accessible to all staff. Staff we spoke with were aware of what to do in an emergency and demonstrated they knew how to use equipment. 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.

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 practice manager had good oversight of the maintenance contracts in place.We saw that fire, and electrical maintenance contracts were monitored, and checks were carried out in a timely manner. A legionella risk assessment was completed annually, with the most recent one carried out on 10 April 2026. Health and safety risk assessments and audits had been undertaken and risks identified had been addressed. 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 together well to provide safe care that met people’s individual needs. There were a range of clinical and non-clinical roles within the practice. The practice also had systems to ensure safe prescribing by the non‑medical prescriber, including regular supervision and weekly case discussions within clinical meetings. Prescribing activity was restricted to areas in which non‑medical prescriber was trained and competent, such as diabetes management and lower‑limb dressings.

We found training was 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.

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 and all staff had had relevant training. Cleaning schedules were in place and followed. For example, we had seen completed and signed cleaning records demonstrating that routine checks had been carried out. There was a cupboard for all cleaning materials which was clean, tidy, and well organised. Risk assessments and audits were completed, and actions taken to mitigate risks. We saw an infection control audit, which showed the service had monitored compliance. In addition, we spoke with the IPC lead, who told us they had conducted regular audits and maintained oversight to ensure standards were upheld.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened. Our review of records showed regular medicine reviews were carried out for people who used the service to ensure their medicines were safe and appropriate for their needs.

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. Blank prescriptions were stored in a safe location and were locked away.

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, vaccines. We saw logs of checks to fridge temperatures that stored medicines and checks staff carried out to monitor expiry dates of medicines. Waste medicines were recorded and disposed of appropriately. The provider had effective systems to manage and respond to safety alerts and medicine recalls.