Claverley Medical Practice

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.

The provider had made improvements in the following areas:

The system to review and act on patient safety alerts was now effective.

Medicines that required monitoring were prescribed safely in accordance with national good guidance.

Dispensing incidents were logged, investigated and the necessary actions implemented to mitigate the risk of them from reoccurring.

Standard Operating Procedures covered standard practices including all aspects of the dispensary. Checks had been implemented to ensure they were being followed.

Dispensary staff had received training to carry out their roles effectively and safely and records of competency checks for longstanding dispensary staff had been implemented.

At our last assessment, we rated this key question as requires improvement. At this assessment, the rating has changed to good.

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 practice 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. The representative from the Patient Participation Group (PPG) felt the provider took concerns seriously and proactively made improvements to the service. There were processes in place for staff to report incidents, near misses and safety events. Leaders encouraged staff to raise concerns when things went wrong. Events were investigated and discussed during staff meetings to allow reflection and learning. Staff felt there was an open culture where they were encouraged to raise concerns. They were able to share examples of events and the action taken.

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.

The practice 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.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. Staff were aware of the processes to follow and how to raise a safeguarding concern. The practice maintained a list of vulnerable people to help staff promptly identify them and act on concerns. There were systems in place to follow up people who failed to attend appointments in primary and secondary care or, people who were frequent attenders at the emergency department.

The practice worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They worked in partnership with other organisations including a local care home, hospice and community teams. Multidisciplinary team meetings were held regularly to raise awareness and discuss vulnerable groups of people. The practice had not been able to secure meetings with health visitors due to continued constraints. However, staff had access to contact details should they need to raise any potential safeguarding concerns.

The practice worked with people to understand and manage risks. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Patients were advised on risks related to their condition and actions to take if their condition deteriorated

Emergency equipment was available and maintained with regular checks carried out. Staff could recognise a deteriorating patient and described the action they had taken as a team during an unexpected acute medical emergency. They worked effectively together and in collaboration with a range of other health personnel.

The practice had a designated person responsible for workplace health and safety. The practice detected and controlled 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. A range of health and safety risk assessments and audits had been undertaken; however, assessments had not been signed by the designated person as an accurate reflection of the health and safety condition of the premises and the safe use of a portable heater in a clinical room had not been assessed or included on the risk register. There was a business continuity plan in place which was monitored and reviewed.

The practice had an established team of clinical and non-clinical staff with many having worked at the practice for a number of years. Historically, the recruitment and retention of doctors has been difficult due to the rural location and geography of the practice. Leaders 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 Patient Participation Group (PPG) representative told us the closure of the provider’s other practice had enabled staff to focus on the needs of patients registered at this practice better. They considered staff were less stretched and were able to provide improved continuity of care.

There were a range of clinical and non-clinical roles within the practice. 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. Staff told us they were provided with good training opportunities, and their learning and development needs were identified and discussed with them as part of their annual appraisal. No new staff had been employed, however we sampled 2 existing staff files and found safe recruitment practices were followed. The practice had gained written assurances from their Primary Care Network (PCN) confirming the safe recruitment and training of staff employed through the Additional Roles Reimbursement Scheme (ARRS), a government initiative that provides funding to Primary Care Networks (PCN) to support the recruitment and retention of new healthcare professionals within their teams was maintained.

The service assessed and managed the risk of infection. The practice had a designated infection, prevention and control (IPC) lead and all staff had had relevant training. Cleaning schedules were in place and staff had access to adequate supplies of personal protective equipment and arrangements were in place for the disposal of clinical waste. An internal IPC audit had been undertaken in June 2025, and no risks had been identified.

The practice was found clean and hygienic on the day of the site visit.

The practice 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.

Staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely. A clinical pharmacist practitioner worked directly with patients to optimise medication therapy and improve patient outcomes. People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms.

Governance arrangements in the dispensary had improved. Staff received regular training, were competency assessed on medicines optimisation, and felt confident managing the storage, administration and recording of medicines. Staff managed prescription stationery appropriately and securely. Staff followed protocols to ensure they prescribed all medicines safely, and ensured most people received the recommended medicines reviews and monitoring. Our remote clinical searches identified potential harm to 1 patient with a long-term condition, records showed despite a number of recalls the person was non-compliant with their monitoring. The national GP patient survey 2025 results for the practice showed 76% respondents felt they had enough support from local services or organisations in the last 12 months to help manage their long-term conditions or illnesses. This was higher than the local average of 71% and the national average of 69%.

Medicines including controlled drugs were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines, vaccines, and controlled drugs. Waste medicines were recorded and disposed of appropriately including medicines returned by patients. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments.

The practice had effective systems to manage and respond to safety alerts and medicine recalls. Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring. There were suitable processes for staff to follow when dispensing medicines. Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. However, prescribing data reviewed as part of our assessment showed the number of antimicrobials issued by the practice was higher than local and national averages in addition to hypnotics (sedatives) and opioids (a broad group of pain-relieving medicines). Leaders considered this was due to having a higher population of older people and providing a service to a local care home.

There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.