Mayfield 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 the service was managed by a different provider and when we inspected the service, we rated this key question as good. This was the first assessment of the service under the new provider and the rating of this key question has changed and is now requires improvement.

The service is in breach of legal regulation related to safe care and treatment.

This service scored 56 (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 positive culture towards safety, based on openness and honesty. Managers encouraged staff to raise concerns and we heard from staff that managers listened and responded to concerns. When things went wrong staff apologised and supported people.

Systems and processes existed to enable incidents to be reported, investigated and monitored for patterns. Incidents were discussed during staff meetings to learn from and make changes to improve care and the quality of the service. Our sampling of significant event reports showed learning was found and action aimed at preventing the incident recurring was taken.

The service did not always manage or monitor people’s safety, however they 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.

Our assessment involved completing remote clinical searches of the service’s clinical system. During our review, we identified 70 tasks assigned to a particular staff member dating back to January 2026, of which 29 had not yet been viewed. We reviewed the tasks and found no urgent items or immediate safety risks to people. The service promptly reviewed the finding in full and told us the cause was because of a change to the process to allocate and monitor tasks which occurred in January 2026. Changes were made to improve the process immediately.

However, we found referrals by the service were managed in a timely way. There was an embedded system to monitor and audit urgent referrals for suspected cancer diagnosis. The process included sending a text message reminder to people to contact the service if they had not received an appointment within the timescale they had been advised. The service also monitored the status of the referral so it could act promptly if it was rejected.

Staff told us they had good relationships with other services such as the community diabetic and tissue viability nursing teams. This meant that as well as formal referral processes, they could contact the teams to make them aware a referral had been made but request advice during the interim period to ensure safe care was provided.

There were systems in place for processing information relating to new people using the service and the service worked with other providers to deliver shared care and when people moved between services.

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.

A safeguarding policy was in place and known by staff. This confirmed a named lead and deputy were in place as well as a safeguarding administrator to support the service to fulfil its duty to safeguard vulnerable people. The service maintained a list of vulnerable people and acted on concerns by working in partnership with other organisations. Staff we spoke with provided examples of how they had acted to protect and support vulnerable people.

The service’s policy confirmed training requirements were aligned to national guidance for safeguarding adults and children, and the frequency which the service required training to be recompleted. We sampled the training records of 4 staff and found 3 were up to date with training, but 1 was not. The service explained the cause was because they had recently changed the interval which training had to be recompleted. We spoke with the member of staff during the assessment who confirmed they could identify safeguarding concerns and knew the action to take to protect potentially vulnerable people. We were also given evidence that all staff in the service were booked onto a safeguarding training course in the next few weeks.

Our sampling of 4 staff recruitment records found all had Disclosure and Barring Service (DBS) checks in place to ensure their suitability to be employed and work with vulnerable people.

The service did not always work well with people to understand and manage risks. They did not always provide care to meet people’s needs that was safe and supportive.

Our remote review of clinical records indicated people had been prescribed medicines contrary to safety alerts issued by the Medicines and Healthcare products Regulatory Agency (MHRA) which meant people had not been fully informed about the risks when making decisions about whether to take these medicines. Our search found 4 people prescribed a dosage of a medicine used to treat depression that was contrary to the advice in the safety alert. Records showed the service had recently identified this group of people following our announcement to assess the service and had already taken steps to contact 3 of the 4 people to discuss the risks associated and options.

Medicine reviews had not always involved people and were not always in line with expected standards. This meant people were not helped to understand how to manage their medicines safely. For example, it was unclear from the clinical notes reviewed whether the clinician had checked a person’s monitoring was up to date in 1 medicine review and in another, there was no evidence a discussion had been held with the person regarding them taking a combination of medicines contrary to a safety alert from the MHRA.

However, staff could recognise a deteriorating person and knew the action to take to support them.

The service did not always detect and control potential risks in the care environment to ensure facilities supported the delivery of safe care.

The service’s premises was set over 2 floors, and people had access to the first floor for the purpose of receiving care and treatment. We found not all environmental risks associated with this had been fully considered to ensure the safety of people using the service. For example, there was no evacuation chair available and the service was unable to confirm if it would be appropriate for use should a person deteriorate while receiving care and treatment on the upper floor. Although the service had considered the risk of a deteriorating person, this was not in a documented risk assessment. When we highlighted this to the provider, a risk assessment was promptly completed detailing the control measures to be used to manage and mitigate the risk regarding a deteriorating person, but this did not include reference to the event of a fire.

Emergency medical equipment was held in the premises and all staff knew the location of the equipment. They also were clear about how they could alert others if they needed help in a medical emergency. We reviewed the stock held and found not all items recommended in national guidance were stocked in the emergency equipment. Some such items were available elsewhere in the premises, whereas others were not stocked. For example, spare adult automated external defibrillator (AED) pads, portable suction and a supraglottic airway device which is typically used to maintain an open airway. The provider had not completed a risk assessment to determine which items to stock. The provider acted by adding some items immediately and completed a risk assessment to determine which other items would and would not be added to the equipment. Where items were not added, rationale and control measures to lower the risk were included in the risk assessment.

There was a system to monitor expiration dates and stock levels of emergency equipment and medicines but when we reviewed the records of monitoring, we noted the system was not working effectively due to gaps in monitoring in February and March 2026. The provider confirmed this was an oversight issue due to a recent change in process.

There was a business continuity plan in place which was monitored and reviewed. Health and safety risk assessments related to the risk of legionella, fire, gas and electrical safety had been completed by external contractors. Systems and processes were in place to detect the risk of legionella in the water systems. These included testing temperatures of the water supply and flushing rarely used water outlets. Fire safety equipment had been tested recently. Fire evacuation drills were completed. Areas for improvement had been previously identified and recorded in a significant event report with learning shared and a repeat drill had been completed which showed improvement in performance. Emergency lighting had been tested and although some items had failed testing, an action plan had been made to maintain people’s safety while repairs were completed. This included emergency torches for the identified locations.

Systems to ensure safe recruitment of staff were not always effective. There were enough staff, but the service did not always make sure staff received effective support and development.

Recruitment checks for staff were not always completed in line with national legislation. We reviewed 4 staff recruitment files and found 1 member of staff had not had a pre-employment health assessment to identify any adjustments needed to help them carry out their role.A further 2 members of staff did not have a documented reason for gaps in their employment history. During the assessment the service confirmed a full review of the service's policy regarding pre-employment checks was in progress and afterwards provided information that these gaps were historical dating back many years before the staff members were employed by the service.In addition, 1 staff member’s appraisal had not been signed or finalised by their manager and another had not received an appraisal in the timeframe according to the provider’s own policy.

The provider told us they were already aware recruitment records were not complete for all staff. We were given a significant event report and noted the service had identified 5 of 9 clinical staff had not had a DBS check by the service since they began employment. The service already had an action plan to review all staff files to improve overall compliance. Action had been taken to apply for DBS checks for the staff identified, with a risk assessment used for the interim period while the DBS checks were carried out. The review of pre-employment checks which was in progress at the time of our onsite visit and was classed as a priority action by the service.

The service had a policy which confirmed the training staff were required to complete. We sampled the training records of 4 members of staff and found 2 were up to date with training required by the provider, although 1 member of staff had training due to expire on the day of the onsite visit. The service confirmed after our visit this had been completed on the day so did not expire. The other member of staff’s training record showed they were overdue sepsis awareness training. The provider gave us an explanation about how they were assured this member of staff had the necessary skills and knowledge. We spoke with the member of staff and they were able to demonstrate appropriate knowledge around sepsis and what they would do if sepsis was suspected. The provider also explained they were transitioning between an old and new system to provide better oversight of training compliance and recruitment checks.

Clinical staff had a dedicated supervisor for advice and guidance on the day and received clinical supervision to support them to develop in their roles. Audits were used to ensure the quality and effectiveness of care delivered by staff working in advanced clinical roles. This included non-medical prescribers.

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 service had a designated infection prevention and control (IPC) lead and all staff had received relevant training. Cleaning schedules were in place and followed. The service had previously identified the quality of cleaning by the external contractor had not been of satisfactory quality. As a result, the service’s IPC lead had been supported by leaders to act and replace the contractor. Leaders reported this had led to an improvement in quality which reduced the risk of infection spreading in the premises. We observed the premises to be visibly clean during our onsite visit.

Risk assessments and audits were completed, and actions taken to mitigate risks. For example, we noted the service’s own audits had identified shelves in clinical areas to be cluttered. Action had been taken to clear the shelves and the issue was raised at staff meetings to explain the risk and reason for keeping shelves clear of clutter. We observed shelves in clinical rooms to be clear and free from clutter and dust.

We sampled the immunisation records for 4 members of staff and found 1 member of clinical staff did not have a record of immunisation for diphtheria, tetanus or polio. The provider was already aware following their own audit and had taken appropriate action in response. This included completing a risk assessment for the staff member and a risk register entry to maintain oversight of the risk. An audit of all staff records was also being completed to confirm whether there were any other staff with missing immunisations.

The service did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not always involved in planning.

The service had introduced a new system to manage and secure prescription stationery. but this was not operating effectively. The stock recorded on the tracker did not match the physical stock held, providing insufficient assurance that all stationery was accounted for. The service acted promptly by, initiating an investigation, auditing stock, and notifying relevant authorities.

Remote clinical searches reviewed prescribing of a medicine used to treat hypertension, heart failure and chronic kidney disease. This medicine requires regular monitoring due to associated risks. Of 46 patients potentially overdue monitoring, a sample of five records was checked and concerns were identified in four. These included prescribing without confirming monitoring was up to date and not considering reduced quantities where patients had not engaged with recall. This was raised with the provider, who submitted an immediate action plan to improve care and treatment.

We also completed a clinical search of people with a potential missed diagnosis of diabetes. We reviewed the records of 5 people from 16 identified during this clinical search. Of those 5, 2 people had not been followed up in the recommended timeframe for further tests to confirm their diagnosis. The service had identified these people prior to the assessment and could demonstrate they had informed them they were at risk of diabetes and follow-up tests were already booked.

Our remote clinical searches looked at medication reviews for people prescribed medicines used to treat neuropathic pain and occasionally epilepsy which are controlled drugs and can be subject to abuse and misuse. We sampled 5 such medicine reviews, of which 3 were not in line with expected standards because they did not involve adequate review or discussion about medicine usage or reduction due to the risk of misuse.

Staff regularly checked stock levels and expiry dates for all medicines, including emergency medicines, vaccines, and controlled drugs. During our onsite visit, we undertook a random sample of medicines and equipment checks and found all to be within their expiry dates. Medicines were stored securely and at appropriate temperatures. Staff administered medicines under patient group directions (PGDs) and patient specific directives (PSDs) which were authorised correctly.

Staff took steps to ensure they prescribed antibiotics appropriately to optimise care outcomes. Prescribing data reviewed as part of our assessment confirmed this. For example, the number of antimicrobials issued by the service was lower than local and national averages. Clinical audits of prescribing focused on improving care and treatment were used. We saw evidence of an audit of broad-spectrum antibiotic prescribing which identified the reason for surges in prescribing of antibiotics was the flu season and provided a finding to improve the service’s performance against antimicrobial stewardship principles by using alternative antibiotics where appropriate.