Trinity Medical 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 have rated the practice as good for providing safe services as we found a strong, open and embedded culture in respect of patient safety, and the practice used every opportunity to learn from incidents. There were systems in place to ensure people were safe and safeguarded from abuse. Staff understood and managed risks. The facilities and equipment, at both locations, met the needs of patients and were clean and well-maintained. Staff had the right skills, qualifications and experience. Managers made sure staff received training and undertook regular one-to-one meetings, and appraisals to maintain high-quality care. There were systems and processes in place to support medicines management. A review of patient clinical records found that overall patients’ medicines and treatment were safely managed by the practice.

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.

We observed a genuine open culture in which all safety concerns raised by staff were highly valued and integral to learning and improvement. Lessons were always learnt to continually identify and embed good practice from incidents, complaints and audits. We saw that the practice had systems and processes in place, underpinned by policies and nominated leads, to formally report, manage, investigate and learn from all incidents. In October 2024, the practice had initiated a new system to report incidents through a link on their clinical system. Incidents were immediately assessed to determine their potential severity and to consider if any remedial or urgent action was indicated. We saw incidents were categorised by type, which included patient safety, medicines safety, data breach, health and safety and zero tolerance. Each category also had a named lead to further support on the investigation and outcomes of reported incidents. The practice tracked risk through a RAG (red, amber, green) rated live risk register. All staff were able to explain the process and told us the new system was accessible, convenient and encouraged all incidents, no matter how small, to be reported. They told us there was an no blame and open culture in which to report incidents. We saw that there had been 137 incidents reported since the new system had been introduced. Incidents were discussed by category in the form of a formal presentation and case reviews at monthly meetings. This enabled the practice to continuously review cumulative trends and themes. The presentation and minutes of these meetings were available to practice staff. The practice maintained a management digital dashboard to document and track all feedback and learning. We saw evidence in the investigation of an incident that the practice had applied the duty of candour.

Learning and outcomes from incidents were shared with other allied health professionals and health services aligned to the practice, for example primary care network (PCN) staff. Wider learning was fostered by sharing incidents with other member practices in the PCN and the Integrated Care Board (ICB).

Leaders told us they worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed and monitored. We found the practice had formal policies in place to manage referrals, clinical correspondence, pathology results and medical record summarising. We observed that urgent suspected cancer referrals were managed appropriately, and a system was in place to ensure they were sent in a timely manner and that patients had received an appointment. The practice had undertaken an audit to ensure the effectiveness of their process to ensure that patients had attended an appointment, and that an outcome had been received by the practice. Pathology results were actioned by clinicians and there was an allocation system in place for when staff were absent to make it fair and equitable. In addition, there was a system in place for safety-netting cervical screening undertaken at the service, ensuring that a result was received for each cervical screening sample undertaken by their sample takers. We saw incoming patient correspondence was appropriately managed and actioned, including changes to patients’ medications, which was undertaken by the clinical and pharmacy team. Clinical records of new patients were mostly received by electronic transfer and those that were received in paper form were summarised in the practice’s clinical record system. We saw that 92% of records had been summarised. At the time of the assessment, the practice had not completed an audit of the summarising process but advised us that they had now updated their policy to add this to their audit schedule to ensure medical records were summarised in line with their policy.

The practice had systems and processes in place to identify, record and action safeguarding concerns, which were underpinned by safeguarding policies. There was a clinical safeguarding lead and deputy for both adults and children. We saw there were systems in place to follow-up on children with frequent attendance at accident and emergency, and when children had not been taken to secondary care appointments or for childhood immunisations. Staff feedback indicated that all staff knew who the safeguarding children and adult lead was and how to access safeguarding policies. Records showed that staff had undertaken training, relevant to their role, for safeguarding children and adults, preventing radicalisation, Mental Capacity Act (MCA), Deprivation of Liberty Standards (DoLS), learning disability and autism awareness. Staff we spoke with were able to give examples of how they would report and escalate safeguarding concerns. There were systems in place to identify vulnerable patients on their clinical records and staff were aware of this. As part of this assessment, we reviewed 2 safeguarding records with the safeguarding adult lead and found evidence of safeguarding alerts and appropriate codes on the records of children and their siblings. They demonstrated how they used a coding system to identify and flag potential safeguarding risk. In addition, the safeguarding lead, in collaboration with the practice’s care coordinators, had developed a self-neglect pathway which provided structured support for vulnerable patients and facilitated escalation in care when necessary. We saw there were regular multi-disciplinary safeguarding meetings and safeguarding leads attended quarterly local meetings. Staff who acted as a chaperone were trained for the role and had received a Disclosure and Barring Service (DBS) check.

Staff were confident in the systems and processes to respond to medical emergencies. Patients requesting care and treatment were signposted by trained care navigators in the access team, who were supported by a dedicated daily duty GP, who ensured patients received the correct care and treatment in an appropriate timescale. Non-clinical staff demonstrated they were aware of ‘red flag’ presenting complaints, for example patients with shortness of breath, and what action to take if they encountered a deteriorating or acutely unwell patient.

At our on-site visit of both sites, we observed that the practice was equipped to respond to medical emergencies, including suspected sepsis. We reviewed processes around the management of emergency equipment and medicines and saw there were regular checks in place, which were recorded. Records confirmed that staff had completed basic life support and sepsis training relevant to their role. Staff feedback demonstrated that all staff were aware of the location of the emergency medicines and medical equipment, for example oxygen and the automated external defibrillator (AED). We saw equipment and medicines available at each location were identical for consistency. Staff were aware of how to raise the alarm in the event of an emergency and told us they used the panic alarm system integrated into their clinical system.

The practice had a facilities manager as part of the management team. During our assessment, we found appropriate maintenance contracts and risk assessments in place for both sites. We saw documentation for the fire alarm system, fire extinguishers, portable appliance testing (PAT), calibration of medical equipment, gas safety certificate, Electrical Fixed Installation Condition Report (EICR) and Lift Operations and Lifting Equipment Regulations (LOLER). Risk assessments had been undertaken for fire, health and safety, Control of Substances Hazardous to Health (COSHH) and Legionella. Where remedial work had been identified the practice were working with contractors to rectify these within stated timescales. At the time of our assessment, the main surgery was in the process of a major refurbishment, and we saw some interim health and safety and fire risk assessment had been undertaken where staff and service functionality had been affected by the refurbishment. The practice told us a repeat premises and fire risk assessment would be undertaken following completion of the refurbishment. We saw that staff had undertaken health and safety and manual handling training. There was a record of regular fire alarm testing and fire evacuation drills for both sites. There had been a fire evacuation drill undertaken at the main surgery since the refurbishment work had commenced. All staff had received fire awareness training and there were nominated fire marshals, who had been trained. There was appropriate fire policies and signage in place, such as for fire escape routes and the fire assembly point.

The practice ensured there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. The leadership team told us that the continuing development of staff skills, competence and knowledge was recognised as integral to ensuring high-quality care, and staff were proactively supported to acquire new skills. In particular, we saw some staff members had trained and upskilled from receptionists to become healthcare assistants, and a healthcare assistant had trained to become a nursing associate.

At the time of the assessment, the practice was streamlining their human resource processes through an electronic portal and had engaged an external human resources service to ensure compliance and to support the growth and development of their workforce. During this process, the practice had identified some potential gaps in their system and processes to ensure all recruitment documentation was captured at the point of recruitment. In response to this the practice had updated their recruitment policy, initiated a recruitment check list and were systematically reviewing all staff files in the transfer to the electronic portal. As part of our on-site assessment, we reviewed 3 clinical and 1 non-clinical staff recruitment file and found appropriate employment documentation in place. For example, photographic identification, references, Disclosure and Barring Service (DBS), professional registration checks and employment contracts.

We saw there was a structured approach to induction, training and appraisals. Staff we spoke with told us their induction was tailored to their roles and included a period of shadowing colleagues. Staff had quarterly one-to-ones with their line manager and staff who had been at the practice for more than a year had received an appraisal.

The learning needs of staff were identified through a system of appraisals, meetings and reviews of practice development needs. Staff had access to appropriate training to meet their learning needs and to cover the scope of their work. We saw that the practice had a mandatory training and frequency schedule in place for clinical and non-clinical staff. There were systems in place to monitor when mandatory training updates were due.

The practice was a teaching and training practice and demonstrated a strong education and learning ethos. Clinical staff in autonomous roles, for example advanced clinical practitioners, told us they had a clinical supervisor and debrief sessions, which gave them the opportunity for both real-time and retrospective evaluation of clinical decision-making in patient care. They told us they felt fully supported clinically. The practice did not have a formal process to document the case reviews for their staff or the primary care network (PCN). However, immediately after the assessment, the practice updated their audit schedule and implemented a written protocol to formally audit and document consultations and prescribing.

The practice had effective systems and processes in place to assess and manage the risk of infection, in line with current national guidance and standards, which was underpinned by an infection prevention and control (IPC) policy. One of the GP partners was the IPC oversight lead, and the day-to-day delegation of IPC was undertaken by a nursing associate. We saw that formal training to support them in this extended role was scheduled for June 2025. All staff knew who the IPC lead was and had received training relevant to their role. On the day of the on-site assessments, we observed both premises to be clean, tidy and clutter-free. Contract cleaners had access to appropriate colour-coded equipment and cleaning materials. The arrangements for managing waste and clinical specimens kept people safe. We found posters around both sites, including handwashing and clinical waste to support good practice. Appropriate personal protective equipment (PPE) and bodily fluid spillage kits were available to staff. An external audit had been undertaken of the main surgery in November 2023, by the local authority, with an overall attainment of 95%, and we saw that the practice had acted upon remedial actions identified. A formal follow-up audit was due to be undertaken upon completion of current refurbishment work in in July 2025. Monthly internal IPC audits of the premises were also undertaken by the IPC lead, we reviewed the April 2025 audit, which included waste management and hand hygiene. At the branch site an external audit had been undertaken in March 2025 with an overall attainment of 94%, and we saw that the immediate remedial actions had been completed. We saw 2 of the findings related to some consultation rooms being non-complaint with flooring and hand-wash basins. The practice had recently upgraded 5 consultation rooms to meet compliance, and the remaining rooms were scheduled to be addressed at further refurbishment work scheduled for 2026.

We saw that the practice had a system in place to capture the immunisation status of staff at the point of recruitment and referred staff to their occupational health provider when updates were required. The practice was able to demonstrate the immunisation status for staff whose files we reviewed at the assessment. Some staff were highlighted for vaccine updates, and this was being managed by occupational health.

The practice had systems, processes and policies in place to support medicines management. As part of our assessment, a CQC GP specialist advisor (SpA) conducted a series of remote clinical searches of patient records to assess the practice’s procedures around prescribing and medicines management. These searches included patients prescribed disease-modifying antirheumatic drugs (DMARDs), medicines which required patient monitoring, medicines subject to a patient safety alert, medicines usage and medicines reviews. The practice demonstrated that they ran monthly medicines searches, including the CQC searches used as part of this assessment, to ensure monitoring was in line with guidance. Patients who did not attend for reviews were discussed and a management plan initiated.

With regards the management of patients prescribed a DMARD, overall, the GP SpA found there was a good system in place for monitoring these patients. We saw there were 60 patients prescribed the DMARD methotrexate, of which 3 patients had not had the required monitoring. One of the patients was known to the practice, had been discussed and flagged on the clinical system and an appointment had been booked. The other 2 patients were under review by the hospital. We discussed with the practice that the day of the week on which this medicine should be taken was not included on the prescription in line with guidance. The practice told us they would raise this with all clinicians who undertake medicines reviews to ensure this was included going forward.

For patients prescribed medicines requiring monitoring, there were 632 patients prescribed a direct-oral anticoagulant (DOAC) of which 203 had not had the creatinine clearance calculated in the last year, although the search does not determine when the patient commenced on the medicine. Creatinine clearance is a measure of how efficiently the kidneys filter creatinine from the blood and calculated on age, weight and creatinine blood test. We reviewed 3 patients and highlighted a patient for further review and written feedback was provided by the practice. The practice told us that they had implemented a pop-up reminder on their clinical system to prompt the calculation of creatinine clearance when prescribing a DOAC in conjunction with the use of an appropriate template by their clinicians.

We reviewed the systems and processes in place to receive, disseminate and act upon patient safety alerts. Overall, the findings of our clinical search indicated a structured approach. We highlighted a patient from the search for further review and received written feedback from the practice.

A review of medicines usage, in particular the number of patients issued more than 12 short-acting beta 2-agonist(SABA) inhalers in the last 12 months showed that from the 7 patients identified they had been managed in line with guidance.

There was a process in place for the safe handling of requests for repeat medicines and evidence of medicines reviews for patients prescribed repeat medicines. We saw there had been 1,956 medication reviews for all ages in the last 3 months. Overall, we found good reviews although it was noted that some medicines were not linked to the presenting problem. The practice addressed this immediately after the assessment.

At our on-site assessment of both sites, we found vaccines were appropriately stored, monitored and transported in line with guidance to ensure they remained safe and effective. Medical gases, such as oxygen, were stored safely with appropriate warning signage. Staff had the appropriate authorisations to administer medicines, including Patient Group Directions and Patient Specific Directions. Blank prescription stationery was securely stored, and their use was monitored in line with national guidance.

Data showed that the practice had systems in place to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. We saw that outcomes were broadly in line with average outcomes.