Norvic Family Practice Also known as Victoria Health 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

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 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. 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. Evidence provided showed that the practice had recorded a total of 4 significant events in the past 12 months. A thematic review was completed to identify any trends in events that occurred and to mitigate any future risk.

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 patients 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. Regular 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 while 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.

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.

Safeguarding meetings were held regularly. Community teams were invited, and information was shared appropriately for the care of people with safeguarding and vulnerable concerns.

Records we examined showed that all staff had a disclosure and barring service (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. They knew of the action to take if they encountered a deteriorating or acutely unwell patient and had been given guidance on identifying such patients. Patients were advised on risks related to their condition and actions to take if their condition deteriorated. Emergency equipment was available and maintained.

The practice 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. The practice had a plan in place to monitor the premises to mitigate risks. 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 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. A fire risk assessment had been completed in December 2025.

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

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 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.

Evidence provided demonstrated systems were in place for the monitoring of staff, which included regular conversations as part of their clinical supervision. 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.

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 3 personnel files and found appropriate checks such as previous employment record and proof of identity checks had been completed. Personnel folders were well organised and there was a systematic approach to ensure that personnel folders were managed appropriately.

There were a range of clinical and non-clinical roles within the practice and was a training practice for GP registrars. 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 did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

An infection control audit had been completed in June 2025 to identify potential risks and take appropriate action where required. The practice had achieved 98%. The latest action plan was dated 2025 and areas identified as requiring action had been completed. For example, there was no documented monthly cleaning programme for the vaccine fridge. Monthly cleaning logs were now in place. The leadership team told us that they had been advised in August 2026, that infection control audits were now self-assessments. However, we were unable to gain assurances that there had been any recent audits completed since June 2025. The frequency of audit should be reviewed regularly to meet the changing needs of the service, patients, and the environment, and to continuously improve safe cleaning standards.

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 were 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 19 out of 41 patients on these types of medicines who had not had the required monitoring within the past 6 months. We reviewed the records of 5 patients and found 4 patients were overdue monitoring. We discussed the findings with the provider and following the assessment we received assurances that all patients we had identified had been contacted and the practice planned to put on extra sessions for patients to be able to access blood test appointments at the practice.

The practice worked with the clinical pharmacists from the local PCN to monitor people and the prescribing of medicines. The provider was aware of safety alerts issued by the Medicines and Healthcare products Regulatory Agency (MHRA); however, we were unable to gain assurances from the clinical team of the system in place to ensure all alerts were acted on. We carried out a clinical search on ACE/ARB medicines plus aldosterone antagonist medicines used for the treatment of patients with heart failure which had potential risks to cause high potassium levels, to check if patients had a urea and electrolyte (UE) test within the past 6 months. We reviewed a random sample of 5 clinical records and 2 out of the 5 patients were overdue monitoring. Following the assessment, we received assurances that actions had been taken to ensure all patients were followed up appropriately.

Prescribing data reviewed as part of our assessment showed the practice were in line with local and national averages for the prescribing of gabapentoids, a group of medicines used to help with neuropathic pain. During the remote clinical assessment, we carried out a search of patients who had been prescribed these medicines in the past 12 months and had not received a review. The search identified 28 patients out of a total of 231 patients. We reviewed a random sample of 5 patients records and found 4 patients had not had a dosage or medication review.

We carried out a search to identify patients who had received a medication review in the past 3 months. The search identified 952 patients. We reviewed a random sample of 5 records and found thorough medicine reviews had been completed by the GPs and clinical pharmacists for 4 out of the 5 patients.

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; however, we were unable to gain assurances that staff in clinical roles were competency assessed on medicines optimisation. 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.