The Meads Medical Practice Limited

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 patients were protected from abuse and avoidable harm.

At our last inspection, we rated this key question as requires improvement because the provider did not always have systems for the appropriate and safe use of medicines, including medicines optimisation.

At this inspection, we found some improvements had been made. For example, appropriate emergency medicines and risk assessments, patient group directions (authorising staff to administer medicines) were authorised in line with national guidance, and better monitoring for patients prescribed epilepsy medication.

However, we found areas where improvements were still needed. Safeguarding alerts were not consistently applied to household members of children at risk. In addition, some issues identified at the last inspection remained, for example the lack of appropriate monitoring for some patients prescribed medication to manage blood pressure.

At this assessment, the rating remains the same.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider 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.

Patients felt supported to raise concerns and felt staff treated them with compassion and understanding. Managers encouraged staff to raise concerns when things went wrong. During staff meetings, the whole team discussed and learnt from clinical issues. Staff felt there was an open culture, and that safety was a top priority. The provider had processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave patients support. Learning from incidents and complaints resulted in changes that improved care for others.

The provider worked with patients 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 patients moved between different services.

There were systems in place for processing information relating to new patients. The provider worked with other healthcare professionals to deliver shared care and when patients moved between services. Referrals and test results were managed in a timely way.

There were systems and processes in place to flag records for vulnerable children and adults. A review of children safeguarding records showed that alerts were appropriately placed on clinical records, however alerts were not always placed on their household family members. This can result in critical information about potential risks being missed. We raised this with the practice and leaders confirmed a policy was in place for coding and linking records of at-risk children's family members. They acknowledged that while family members had been linked, coding was incomplete. Leaders acted promptly to address this and shared their action plan with us to review their safeguarding register.

The provider worked with patients and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving patient’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

Staff had access to adult and children safeguarding leads in the practice and could also escalate concerns externally if required. Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. The practice maintained a list of vulnerable patients and acted on concerns; working in partnership with other organisations. A review of safeguarding meeting minutes showed the practice actively engaged and contributed to collaborative working.

There were notices in the practice showing that chaperones were available if required. We saw that staff who acted as a chaperone were trained for the role and had received a disclosure and barring service check (DBS). (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).

Staff told us if children or vulnerable individuals were not brought to their appointments or failed to attend, this would be identified for follow up action. Staff told us this approach helped ensure that early warning signs were not missed and that necessary interventions could be put in place.

The provider worked with patients to understand and manage risks by thinking holistically. They provided care to meet patient’s needs that was safe, supportive and enabled patients 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. Patients were advised on risks related to their condition and actions to take if their condition deteriorated

National GP patient survey data for 2024 showed 98% of respondents said they were involved in decisions relating to their care. This was above the national average.

The provider identified, assessed and managed potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

We found there was assisted entry into the practice and access to chairs with arms in the waiting areas to assist those with limited mobility. There were appropriate baby changing facilities.

The provider’s last fire risk assessment was in January 2024, with the next scheduled for May 2025. Identified risks had been addressed, for example ensuring fire doors were not wedged open and sealing gaps in the ceiling of a room with fire resistant material.

Staff had completed annual fire safety training and staff appointed as fire wardens received appropriate training. We saw fire safety wardens were on duty during our onsite visit.

There were established and effective systems in place to identify, manage and mitigate risks to patients. Health and safety risk assessments and audits had been completed in February 2025 and risks identified had been addressed. For example, ensuring floors were kept clear of trailing leads and cables. Contracts were also in place to ensure the premises and equipment were maintained. For example, routine legionella testing, portable appliance testing and equipment calibration were routinely conducted by an external company.

The provider 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 patient’s individual needs.

There were a range of clinical and non-clinical roles in the practice. We found training was up to date, learning needs and development of staff was managed appropriately, and staff were working in their agreed areas of competence. Safe recruitment practices were followed.

Staff told us appropriate staffing levels and skill mix were maintained to make sure patients received consistently safe, good quality care that met their needs.

Staff performance and conduct was monitored, and poor performance was addressed. This was achieved through supervision, appraisal and support to develop and improve services.

The provider identified, assessed and managed the risk of infection. They mitigated the risk of it spreading and shared concerns with appropriate agencies promptly.

There was a designated infection, prevention and control lead and all staff had received relevant training.

Staff had access to gloves, aprons and masks to mitigate the risk of infection to patients. Policies were in place that outlined how staff should triage and manage patients with potentially contagious diseases.

Cleaning schedules were in place and followed.

The provider carried out annual infection prevention and control (IPC) audits, with the most recent conducted in September 2024 and identified actions had been address. For example, preventing overfilled sharps bins, incorporating hand hygiene training into the staff induction programme and resolving maintenance issues in patient areas.

During our site visit we saw the practice had maintained appropriate standards of cleanliness and hygiene. The practice employed an external cleaner, and we saw that cleaning schedules and Control of Substances Hazardous to Health (COSHH) risk assessments were maintained and checked by the provider.

Clinical staff used single use items and had access to body fluid spillage kits to mitigate the risk of infection to patients.

Following our last inspection in June 2023, the provider had made improvements including completing monitoring tests for patients prescribed high risk medicines for epilepsy.

At our last inspection, we found some patients who had been prescribed ACE inhibitors (a medicine used for the management of blood pressure) had not received monitoring in line with national guidance.

We had also found that some patients diagnosed with hypothyroidism had not received a review of their care and prescribed medicines in line with national guidance.

At this inspection in May 2025, we saw established systems were not consistently effective in practice. We found some medicines had not been consistently monitored in line with best practice guidance.

We reviewed a sample of clinical records. We found some patients who were prescribed high-risk medicines did not always receive necessary monitoring. For example, we found 4 out of 5 patients prescribed ACE inhibitors had not received monitoring in line with national guidance. The provider had not assessed the patients’ circumstances to determine whether short scripting was appropriate, as per their recall and prescribing protocol.

We found 5 out of 5 patients diagnosed with hypothyroidism and who had been prescribed thyroxine (a medicine used to help restore the hormone thyroxine that helps control energy, metabolism and overall body function) had not received necessary monitoring. This meant the provider could not be assured the medicines prescribed for the management of the condition remained appropriate. The provider had not assessed the patients’ circumstances to determine whether short scripting was appropriate, as per their recall and prescribing protocol.

Following our feedback, leaders acted promptly and implemented an action plan to strengthen their recall and monitoring protocols. However, we were unable to determine the effectiveness of these changes at this assessment.

A review of clinical records showed the provider had effective systems to manage and respond to safety alerts.

Staff received regular training, were competency assessed on medicines optimisation, and felt confident managing the storage, administration and recording of medicines. Medicines were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines. There were appropriate systems in place to ensure the safe storage of medical gases, such as oxygen.

The provider had a system to manage prescription stationary.

There was a programme of regular clinical audits of prescribing that focused on improving care and treatment. For example, ensuring appropriate antibiotic prescribing, identifying patients at risk of chronic kidney disease and optimising chronic obstructive pulmonary disease treatment.