Drs Dawes, Narasimhan and Spiller

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.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. Managers encouraged staff to raise concerns when things went wrong. 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.

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.

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.

There was a system in place to ensure all patient information including laboratory test results and referrals were reviewed and actioned in a timely manner. Referrals to specialists and urgent services, including 2-week-wait (2WW) referrals, were managed through a clear process. The provider told us that there were processes in place that was monitored and managed to keep people safe.

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. 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 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 which 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. Information was displayed on safeguarding processes to ensure staff were equipped to respond effectively to any safeguarding 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.

Staff demonstrated a good understanding of emergency protocols and were trained in basic life support. Reception staff were aware of the actions to take if they encountered a deteriorating or acutely unwell patient and had been given guidance on recognising such presentations.

Patients were advised about risks related to their condition and the actions to take if their symptoms deteriorated. Staff were aware of the location of emergency medicines and equipment, which was appropriately maintained. The practice also held registers to support 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 in August 2025. Staff had been provided with training in health and safety related topics such as fire safety, infection control, basic life support and resuscitation training. Checks were carried out to the internal and external premises annually. Feedback from staff reported 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. Systems were in place for checks of fire alarms, extinguishers and fire evacuation procedures with checks carried out around the building weekly. Clear signage around the building supported people and staff in the event of an emergency evacuation.

Evidence provided by the practice showed equipment was regularly calibrated and electrical items were PAT tested (portable appliance testing). The latest calibration of equipment had been completed in January 2026.

There was a business continuity plan in place which was monitored and reviewed. Reception and administration staff who handled calls to the practice and arranged appointments with the clinical team were aware of potential red flag symptoms. Staff knew when to notify a GP or other clinicians with concerns about a patient who may be acutely unwell and/or deteriorating.

During our site visit, we found that the premises were well maintained, and plans were being developed to potentially increase the building’s capacity.

The service made sure there were enough qualified, skilled and experienced staff, however, the assessment identified that further supervision was required for some staff. We found there were processes in place to ensure clinical oversight and competency for trainee GPs and allied health professionals through regular reviews and audits. However, this level of oversight did not consistently extend to nurse prescribers. Following the assessment, the provider developed an action plan to address this. This included introducing a policy and procedure for auditing non‑medical prescribers and appointing a named supervisor to provide ongoing support and oversight.

Staff received support and opportunities to develop. All new staff underwent an induction programme and were required to undertake mandatory training within an appropriate timescale. There was a system to monitor staff training to ensure mandatory updates were completed and staff were supported to develop their skills and learning. There were systems in place to ensure that staffing levels met the needs of the service. Staff told us that they felt there were enough staff to provide safe care, and they worked effectively as a team.

The practice made sure that staff were suitable for employment. Policies for appraisals and safe recruitment practices including Disclosure and Barring (DBS) and registration checks were in place. We reviewed 4 personnel files and found appropriate checks such as previous employment record, immunisation status and proof of identity checks had been completed.

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 (IPC) lead, and all staff had completed relevant training including additional FIT testing training for clinicians for FFP3 masks. Cleaning schedules were in place and followed. Risk assessments and audits were carried out, with actions taken to mitigate identified risks. We saw evidence that the practice routinely completed legionella risk assessments and water quality testing. Quarterly IPC audits were undertaken, and the most recent audit, covering October 2025 to January 2026, showed the practice had achieved a compliance score of 92%. Actions identified included replacing a damaged couch. Other audits completed included annual hand hygiene, minor surgery and medical equipment audits.

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.

The practice was supported by clinical pharmacists from the local Primary Care Network (PCN) to monitor people and the prescribing of medicines. As part of our assessment, we carried out remote searches of clinical records to check how the practice monitored patients’ health in relation to the use of high-risk medicines.

Clinical searches identified 75 patients prescribed disease‑modifying antirheumatic drugs (DMARDs) for the treatment of autoimmune conditions. We found that all of these patients, including the 5 sampled had the required monitoring within the last 12 weeks.

A second search showed the number of people who had been prescribed medicines to reduce the risk of blood clots forming called direct oral anticoagulants (DOACs), who had not received the appropriate monitoring in the past 6 months. The search identified 69 patients on these medicines who were overdue blood monitoring. We reviewed 5 clinical records and found 2 people had up to date renal monitoring and 3 people had renal bloods in the last 10 months. We found 4 out of 5 people had been invited for blood monitoring.

Our remote clinical searches found 1421 patients had received a medication review in the previous 3 months. We reviewed a random sample of 5 clinical records from medicine reviews completed by either a GP or a nurse. While the reviews had been completed, they lacked sufficient context, making it unclear what discussions had taken place during the review. This feedback was shared with the practice.

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 able 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 women of childbearing age prescribed teratogenic drugs, medicines that had the potential to increase the risk of birth defects. The clinical search identified potentially 65 patients on this medicine. We reviewed 5 records and found the appropriate clinical reviews were in place. Other searches carried out in relation to safety alerts showed good compliance in place. 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. 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 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.