Dr A Riaz and Mrs Shabana Riaz

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 66 (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. Staff were able to share examples of incidents, actions taken and lessons learnt to continually identify and embed good practice.
People felt supported to raise concerns and felt staff treated them with compassion and understanding. A representative 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. During staff meetings, the team discussed and learnt from incidents and complaints. Staff felt there was an open culture, and that safety was a top priority.
The service had processes for staff to report incidents, near misses and safety events. An analysis of incidents over the previous 12 months had been carried out, which found no recurring systemic failures. Each event was used to strengthen systems, improve patient safety, support staff learning and enhance governance.
Leaders told us they continued to embed a positive safety culture. Leaders had developed a staff newsletter that was held in the staff room. This included information about incidents that had occurred and reminded staff that every incident reported is an opportunity to improve and build a culture of continuous improvement and high-quality patient care.
There was a system to record and investigate formal complaints, and when things went wrong, staff apologised and gave people support. Leaders agreed to improve their complaints documentation, audit trail and escalation processes in addition to investigating informal verbal complaints to help identify any common trends and themes.
 

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. The service worked with other providers to deliver shared care and when patients moved between services. Referrals and test results were managed in a timely way. There was a process to safety net urgent referrals to secondary care. The practice agreed to strengthen their internal procedures to ensure no high-risk patient was lost to follow up during the diagnostic pathway.
 

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. Staff shared an example of how they had gone above and beyond to help a person who was made vulnerable, working in conjunction with other agencies.
Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. The practice maintained a list of people who are made vulnerable and acted on concerns working in partnership with other organisations. Alerts were seen on the records of adults who were made vulnerable and children at risk, including siblings within the same household for children but alerts had not been placed on the parent records to provide immediate visual warnings to staff. The practice told us they would action this within 1 week.
People who were made vulnerable were discussed during regular interdisciplinary team meetings held and detailed records were maintained. Leaflets and information about abuse was available in the practice to inform both staff and patients and relevant contact numbers and support services.

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 had access to symptoms to support them with recognising symptoms, including sepsis. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

The service detected and controlled most potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.
Contracts were in place to ensure the premises were maintained. Some health and safety risk assessments and audits had been undertaken and risks identified had been addressed. However, we identified some shortfalls in relation to fire safety. For example, the fire alarm was not being tested at the required frequency and some sections in an internal fire risk assessment completed in June 2026 had not been completed. Although the fire system was serviced, no instructions or notices were displayed in the premises to advise people of evacuation procedures or designated fire assembly points. Following our site visit an interim fire alarm and evacuation procedure was shared with us in addition to confirmation that a date had been scheduled for contractors to attend the practice on 30 July 2026, to review the previous recommendations made and ensure compliance.
Designated fire marshals were in place to manage emergencies, but it was difficult to establish if they had received specific training or were fulfilling their role. Equipment to support them, such as high visible jackets, was not readily accessible. The emergency lighting although tested monthly as required, had not been serviced professionally. Plastic 13A plug socket inserts seen in one room were immediately removed during our on-site visit, in line with a safety alert previously issued.

The premises were secure, with restricted access to staff offices and signs informing people that CCTV was in operation.

The service had a business continuity plan which was regularly reviewed and outlined how the service should continue to operate in the event of a disruption.

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. The practice had an established team of staff with many having worked at the practice a number of years and had progressed in their career development.
The service employed a range of clinical and non-clinical roles within the practice. They also utilised staff employed through their Primary Care Network (PCN), enabling a broader range of services to be offered to people. These services included a social prescriber, a GP Assistant, mental health practitioner, physiotherapist, pharmacist, pharmacist technician and a dietician. They worked well together to provide safe care that met people’s individual needs.
We found training was up to date for all but one staff member, learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence. Staff employed by the Primary Care Network and working in the practice completed the same training as the practice staff and their training was managed and overseen by the practice manager. Following our site visit, the practice provided assurance that all staff had since completed their mandatory training.
Staff told us they were provided with good training and learning opportunities. Staff within the nursing team had attended training relevant to their roles and kept up to date with their training and development needs including, external training courses provided by the Staffordshire Training Hub and the local Integrated Care Board (ICB). Leaders told us they were considering sourcing transgender training to support staff and the identified patients. A crib sheet had been developed to support reception staff in the interim. Clinical supervision was held monthly and recorded.
The service did not consistently follow safe recruitment procedures when employing new staff, which were in line with national legislation. We sampled 3 staff recruitment records and identified omissions in some documentation obtained prior to staff recruitment. Following our site visit the provider reviewed and updated their recruitment policy and provided assurances that they had since obtained documentation, including staff health declarations. They told us they would ensure all of the required documentation, including staff immunisation status was obtained prior to the recruitment of any new staff.

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, but 1 member of staff had had relevant training. Following our site visit, the practice provided assurance that all staff had since completed their mandatory training. Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks.
Following our site visit a register was sent to us, detailing the hazardous substances held in the practice and the safe management of associated risks and data sheets obtained.
 

The service generally 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.
People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms. They had access to information to alert them to symptoms, including sepsis.
We carried out remote searches of clinical records as part of our assessment to review how the practice monitored patients’ health in relation to the use of medicines. The searches demonstrated that monitoring processes for high‑risk medicines were effective. We saw evidence that medicine and safety alerts were reviewed and generally actioned, however, not all female patients of childbearing age had been advised of the risks associated with a certain medicine. The provider told us they would take action and review these patients.
Searches relating to the management of long‑term conditions we sampled showed that people were generally well managed and were being followed up and monitored in line with recognised guidance. However, on the records we sampled we found people with asthma were not being reviewed following exacerbations. The provider told us they would implement a robust asthma exacerbation policy for adults and children whereby they would be followed up by the Practice Nurse.
Staff received regular training, were competency assessed on medicines optimisation, and felt confident managing the storage, administration and recording of medicines. Staff followed protocols to ensure they prescribed medicines safely, and ensured people received all recommended medicines reviews and monitoring.
Records we reviewed showed the practice had carried out 356 reviews in the previous 3 months. We sampled 5 of these reviews carried out by GPs and found they were just coded and did not detail what was reviewed and agreed actions. Following our clinical searches the provider told us regular structured medication reviews were undertaken however, they would improve the quality of their routine prescription reviews.
Medicines were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates. Medicines in the event of a medical emergency were available, with the exception of one but were not readily accessible. An alternative storage location was found during our site visit, and a risk assessment was later shared with us in the absence of this medicine not being available due to a national shortage. Staff stored medical gases, such as oxygen, safely. However, effective systems were not in place for the security of or for tracking of paper prescription stationery throughout the practice. The provider told us they would review and improve their processes.
Staff followed processes to ensure people prescribed medicines with specific risks received recommended monitoring. 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 national averages. Patient Group Directives (PGDs), which allow specified health professionals to supply/or administer medicine without a prescription or an instruction from the prescriber were in place and authorised but were not crossed out to prevent additional names being added to the PGD post authorisation. This was immediately rectified by the provider. Patient Specific Directions (PSDs) were in place and managed. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.