Keele 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

This is the first inspection for this service since its registration with CQC with the provider North Staffordshire Combined Healthcare NHS Trust. This key question has been rated as Good.

The service had a good learning culture and people could raise concerns. Managers investigated incidents thoroughly. People were protected and kept safe. Staff understood and managed risks. Overall, the provider had effective systems and processes in place to maintain a safe and well-managed environment. Governance and oversight arrangements supported the identification, monitoring and mitigation of environmental and health and safety risks. Following our onsite visit evidence of remedial actions were provided promptly. Improvements included fire safety enhancements and the installation of a wireless fire alarm system. A risk assessment update was required for the first-floor stairwell bannister area. Following the assessment, the practice organised a review to evaluate the identified risks and determine any further actions required. Actions arising from a 2025 Legionella risk assessment were being monitored, with a further review planned for August 2026.The practice worked collaboratively with relevant estates teams to maintain the premises and plan for the long-term sustainability of the estate. This did not detract from the overall assurance that risks were well understood and managed. Business continuity arrangements were well established and regularly reviewed, supporting organisational resilience and continuity of service delivery.

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.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. Representatives from the Patient Participation Group (PPG) felt the provider took concerns seriously and proactively made improvements to the service. Managers encouraged staff to raise concerns when things went wrong. During staff meetings, the 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 people support. Learning from incidents and complaints resulted in changes that improved care for others.

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. A centralised electronic diagnostic diary was introduced in May 2026, this web-based system managed long-term and acute diagnostic tasks required 4 months or more in advance across all the practices in the directorate (Moorcroft Medical Centre, Holmcroft Surgery, and Keele Practice). It served as a safety net for complex, non-routine monitoring.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations.

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. The introduction of CCTV and associated patient information signage within waiting areas was under consideration to support patient safety and monitoring. The feasibility of these measures was dependent on the constraints of the existing building fabric.

The service detected and controlled potential risks in the care environment. However, some remedial works remained outstanding, and the scope for further improvement was constrained by the inherent limitations of the building’s fabric and infrastructure.

Contracts were in place to ensure the premises were maintained. Health and safety risk assessments and audits had been undertaken and risks identified had either been addressed or had action plans in place.

The practice building was owned by Keele University, with the University estates team responsible for the fabric of the building’s facilities. The Trust estates team, Primary Care Directorate, and University estates team each managed their own realm of responsibilities for maintaining the practice environment. Discussions had taken place regarding the long-term sustainability of the estate; this had included any potential for a new build or estate modernisation. The completed building condition report informed the feasibility of any required remedial works.

There was evidence of regular communication regarding environmental health and safety risk assessments and reviews. We requested evidence of the remedial actions taken when this was not evident in the documents reviewed. These were promptly provided following our onsite visit. Actions, such as changes to fire doors and a new wireless fire alarm system, had been implement immediately after our site visit and evidence provided.

A risk assessment update was required for the first-floor stairwell bannister area and any mitigations of risk to be actioned.

The University estates team provided the practice with evidence of actions taken in response to the February 2025 Legionella risk assessment. A further risk assessment was planned for August 2026 to review and validate progress against any outstanding remedial actions.

There was a business continuity plan in place which was monitored and reviewed.

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. Clinical supervision was undertaken at least every 8 weeks in accordance with policy requirements, although most reviews took place 6 weekly. Supervision sessions lasted a minimum of an hour, dependent on the format and focus of the review. Appraisals included an assessment of training and competency, together with a review of at least 10 clinical consultations. These reviews considered prescribing decisions, investigations, test result management, clinical record-keeping, the provision of information to patients, the extent to which patients were involved in shared decision-making and the development of management plans. Learning disability and autism Tier 1 of 2 training had been completed for all staff. Tier 2 training had been completed for some but not all staff. This was being sourced for all remaining staff. Staff had been in receipt of Jess’s Rule awareness training which is a primary care initiative to encourage GPs teams to rethink a diagnosis if a patient presents three times with the same symptoms or concerns, particularly if symptoms unexpectedly persist, escalate, or remain unexplained. It is led by the Department of Health and Social Care (DHSC) and NHS England and is supported by the Royal College of General Practitioners (RCGP).

We found learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence. These were reviewed during staff appraisals and at clinical supervision sessions.

All staff had been subject to appropriate level disclosure and barring service checks. The Disclosure and Barring Service helps employers make safer recruitment decisions. We reviewed staff recruitment and training records and of the 5 we sampled we found safe recruitment practices were followed.

The service effectively monitored staff attrition and routinely offered exit interviews to staff leaving the organisation. Feedback obtained through completed exit interviews was analysed and used to inform workforce and organisational development plans. The reception/administration team had higher staff turnover with a stable clinical staff team. Staff told us they felt able to raise issues, queries, and concerns, including those relating to staffing levels during periods of annual leave, sickness, and other absences. The provider had strategies in place to optimise staff retention where able and held regular discussions with the non-clinical teams to gain their feedback.

The practice had a designated infection, prevention and control (IPC) lead and all staff had had relevant training. An IPC audit had taken place in July 2025, and the latest hand hygiene audit was dated April 2026. We found staff aware of the IPC leads and of the audits that took place. The practice had an Infection Prevention Control (IPC) action plan following their internal audit with dates set for review and completion. The building condition report had highlighted improvement areas such as new sink units. The completed building condition report informed and impacted on the feasibility of any required remedial works. Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks.

Staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely. People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms. 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 people received all recommended medicines reviews and monitoring. 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. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments.

The service had effective systems to manage and respond to safety alerts and medicine recalls. There were protocols in place which brought to staffs’ attention for example that for the Keele Practice solely there was dual-system monitoring in place together with Newcastle South Primary Care Network (PCN). This shared oversight added an extra layer of clinical governance and resilience. With the collaborative monitoring, staff from Newcastle South PCN concurrently monitored incoming safety alerts via their own processes to ensure no critical safety communications were missed.

The practice maintained a medicine monitoring protocols. These outlined for example the process for monitoring patients prescribed high risk medicines, Direct Oral Anticoagulants, (DOACs are blood-thinning medicines used to prevent and treat blood clots), long term conditions systems and ensuring patients records held Essential Shared Care Agreements (ESCA) when appropriate.

Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring. For example, our clinical searches identified no patients were overdue monitoring for high-risk medicines. The service held Non-Compliance with Drug Monitoring Requirements policy. This referred to measures to encourage compliance and attendance for monitoring and actions such as reduced numbers of days for the prescribed medicine as one of the measures they could use. Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. Prescribing data reviewed as part of our assessment confirmed this. Our clinical searches found there were 630 asthma patients and 4 had been prescribed 12 or more relief inhalers in the past year. We reviewed the 4 records and found the practice had been proactive and had recalled patients for a monitoring review, but patients had yet to respond.

There was a programme of regular clinical audits of prescribing that focused on improving care and treatment. There had been 263 medication reviews in the 3-month period and we reviewed 5. All 5 medication reviews we sampled were comprehensive, good quality reviews conducted by pharmacists.