Scott Road 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 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 has changed to requires improvement.

This service was in breach of legal regulations in relation to safe care and treatment.

This service scored 47 (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 did not always listen to concerns about safety, and did not always appropriately investigate and mitigate against safety events. Lessons were not learnt to continually identify and embed good service.

The service did not always fully respond to drug safety alerts from the Medicines and Healthcare products Regulatory Agency (MHRA). Further details can be found under the key question of safe in ‘Medicines optimisation’.

The service had a process for identifying, reporting and managing significant safety events. However, the service did not consistently recognise or record some significant events, even when there was a clear risk of harm or evidence of unsafe practice. In some instances, the service had failed to respond appropriately to a significant event and failed to mitigate against future risk of the event or a similar event happening again. The service confirmed a system was not in place to analyse the significant events over time to help identify themes and trends.

Staff knew how to escalate and report safety events. Most staff felt able to raise any safety concerns. However, some staff told us they did not think raising a concern would be welcomed or their views would be listened to and acted upon. Although not all staff felt they were made aware of the details of significant events, and not all were involved in meetings to discuss these, most staff told us that any learning (if relevant to their role) was shared with them.

Although key learning points were disseminated to staff, there was no process to ensure learning was appropriately understood by and embedded with all relevant staff.

The service did not always monitor people’s safety by maintaining safe systems of care with health system partners. They did not always ensure continuity of care, including when people moved between different services.

An effective system was not in place to act upon letters from secondary care in a timely and safe manner to ensure individual clinical oversight of each patient concerned. Since September 2024, the service had a regular backlog of approximately 1,700 letters from secondary care requiring review. Although the backlog had been monitored and some mitigating steps taken, the volume had remained largely unchanged (being 1784 at the time of our assessment site visit, with the oldest received by the service 23 days prior).

Staff told us this backlog was under constant review and the service had made changes to try and improve this.

The service had a system in place to ensure referrals and test results were managed in a timely way. We looked at the service’s clinical systems to view the number of patient referrals and test results that were outstanding and required action. All referrals and test results had been actioned. The service also had a system for processing information relating to new patients.

The service did not always work well with patients and healthcare partners to understand what being safe meant to patients and how to achieve that. The service did not always concentrate on improving patients’ lives or protecting their right to live in safety. They did not always share concerns quickly and appropriately.

The service had safeguarding policies and protocols in place, including a process to follow if a child was not brought to an appointment or if a vulnerable adult did not attend. The safeguarding lead had conducted a recent audit (June 2025) into safeguarding action taken following missed appointments. This identified multiple instances where staff had not acted according to the policy in place. The safeguarding lead intends to remind staff of the need to follow safeguarding processes and will complete a re-audit to assess progress toward improvement in this area.

A primary care network (PCN) Safeguarding Care Co-ordinator was in place. They were responsible for maintaining safeguarding registers and ensuring they were up-to-date. However, a system was not in place for checking with the local authority as to whether a child had been removed from their list.

Staff knew who the designated safeguarding lead within the service was. Staff were encouraged to raise any concerns for advice when needed. Staff had access to the service’s ‘Safeguarding Hub’ via a shortcut from their main computer system. This contained all relevant policies and protocols, appropriate contact points for advice and escalation, and the Royal College of General Practitioners (RCGP) ‘Safeguarding Toolkit’. However, not all staff were aware of the availability of this toolkit.

Staff completed safeguarding training based on their role in accordance with the RCGP safeguarding standards for general practice.

Patients were routinely offered chaperones to attend appointments with them if they preferred. We saw information posters about chaperones displayed in the service waiting room and in treatment rooms. Staff had received appropriate training to act as chaperones.

The service worked with patients to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was supportive and enabled patients to do the things that mattered to them.

Patients had access to various groups which offered peer and wellbeing support.

The GP Patient Survey showed 95% of patients were involved as much as they wanted to be in decisions about their care and treatment during their last appointment at Scott Road Medical Centre. This was higher than the local and national result of 91%.

Emergency equipment was available in the service and was well-maintained. All staff were required to complete training in sepsis awareness. Staff could recognise a deteriorating patient and knew how to escalate concerns.

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 service completed health and safety risk assessments and audits, and any risks identified had been addressed. They managed fire safety well. They had a business continuity plan in place which was monitored and reviewed.

We observed the premises to be fit for use. The service had contracts in place to ensure the premises were maintained.

Staff told us they had access to appropriate equipment to safely and effectively perform their role. However, multiple staff did tell us they would benefit from adjustable clinical beds in treatment rooms (for the benefit of both patients and staff). During the assessment, we noted wooden, non-adjustable beds.

The service did not always ensure there were enough qualified, skilled and experienced staff. They did not make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

A policy with clear expectations for staff regarding clinical supervision was not in place. In instances where concerns over staff performance and capability had been raised, the service did not manage this appropriately. Staff did not always follow guidance provided by the National Institute for Health and Care Excellence (NICE). This had led to incidents which negatively impacted the safe care and treatment of patients.

The service employed non-medical prescribing (NMP) staff. NMP refers to the practice of registered healthcare professionals (other than doctors or dentists) prescribing medicines to patients (in this case, some nursing staff). A system was not in place to ensure NMP staff were always up-to-date with their clinical knowledge. The service did not have a system in place to monitor the prescribing practices of NMP staff and to ensure effective oversight of these staff. This had impacted the safe care and treatment of patients.

However, the service had safe recruitment processes in place. Staff had an appropriate level of Disclosure and Barring Service (DBS) check relevant for their role. Staff had access to a comprehensive induction programme.

The service assessed and managed the risk of infection. They detected and controlled the risk of infection spreading and shared concerns with appropriate agencies promptly.

The service had a designated infection, prevention and control lead and all staff had received relevant training. Cleaning schedules were in place and followed. Risk assessments and audits were completed, with actions taken to mitigate risks.

We observed the premises to be clean and tidy throughout.

Some clinical rooms were carpeted. The service confirmed carpets were cleaned annually, but spare carpet tiles were available if any became soiled and needed to be replaced in the interim.

The service did not make sure medicines and treatments were safe and met people’s needs.

As part of our assessment, a CQC GP Specialist Advisor (SpA) completed a series of patient clinical record searches. This included a review of the management of patients on a sample of medicines that require monitoring and a review of prescribing (including the effectiveness and quality of medication reviews completed by the service).

Our clinical searches reviewed patients with heart failure prescribed aldosterone antagonists. Aldosterone antagonists are medicines that block the action of aldosterone, a hormone produced by the adrenal glands. Aldosterone regulates sodium and potassium levels in the body. By blocking its effects, these drugs help the kidneys excrete excess sodium and water, which can reduce blood pressure and relieve fluid retention associated with conditions like heart failure. The number of patients identified by search prescribed this medicine was 62, with 9 identified as not having had the required monitoring. We informed the service this group of patients required urgent review.

Our clinical searches reviewed action taken in response to drug safety alerts from the MHRA. Specifically, combination drug alerts relating to patients prescribed the medicines clopidogrel (a blood thinner) and omeprazole / esomeprazole (used in the treatment of gastroesophageal reflux disease or peptic ulcer disease). Omeprazole/esomeprazole inhibits the effect of clopidogrel, and these medicines should therefore not be prescribed together. The number of patients identified by the search as having been prescribed this combination was 3. The records of 2 of those patients were reviewed. Although there was evidence the MHRA safety alert had been considered for both patients, there was only evidence of 1 patient having been informed of the risks associated with taking this combination of medicines.

Our clinical searches reviewed patients prescribed methotrexate, a disease-modifying antirheumatic drug (DMARD) for the treatment of pain and stiffness in joints caused by inflammation, who require monitoring every 12 weeks. Although we identified patients who had not had the required monitoring in the last 12 weeks the provider was able to explain the reasons for this, for example the medicine had been prescribed and was being monitored by secondary care. However, the practice was not recording the day of administration for methotrexate on the patient record, as required by an MHRA alert issued in September 2020. This evidence was made available to the service in letters from secondary care seen on the patients' records.

Our clinical searches looked at the quality of medication reviews. Specifically, for patients prescribed more than 10 medicines (polypharmacy) who had not had a medication review in the last 18 months. The search identified 586 patients who were prescribed as polypharmacy, with 213 identified as not having had a medication review in the last 18 months. We looked in detail at 5 patient clinical records and found that a medication review had not been coded for at least 18 months in all 5 patient records. Medication reviews are crucial for patients taking multiple medicines because they help identify and address potential risks associated with this (such as adverse drug reactions, drug interactions, and inappropriate prescribing).Reviews are required to ensure patients are taking the right medicines in the right doses, and that the benefits of the medicines outweigh the potential harm.

However, we did not find any concerns over the service’s monitoring of patients prescribed lithium or warfarin.

Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines. Medicines were stored securely and at appropriate temperatures.

The service stored medical gases (such as oxygen) safely and completed required safety risk assessments. They ensured prescription stationery was managed appropriately and securely.