Cardinal 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 assessed all quality statements from this key question. Our rating for this key question is Good. At this assessment we found many improvements had been made since the previous inspection published May 2022. There was a culture of learning from safety events and when things went wrong, staff acted to ensure people remained safe. Improvements had been made to include staff in the investigation and learning from significant events and complaints. Safe systems and pathways were in place when people moved between different services. Improvements had been made to the system and process to ensure all clinical letters had been seen and actioned by appropriate staff. The practice now had a fail-safe system and process to ensure all cervical cytology results were received from samples sent. People were safeguarded from abuse. There were effective arrangements for supporting people to identify and manage risks and systems were in place to ensure the environment was safe to use. Recruitment checks were carried out in accordance with regulations and new staff received an induction to their work. Staff had completed training deemed mandatory and were now trained to the appropriate level for their role in safeguarding. Most staff had received an appraisal in the last 12 months. Staff who had not received one yet, had one booked. There was oversight of the work of clinical staff working in extended roles. Effective systems were in place for the safe management of infection prevention and control. Our clinical searches were mostly positive and showed good care and appropriate monitoring of people prescribed high-risk medicines. Systems had been improved to ensure all safety alerts were acted on to ensure medicines were prescribed safely. Emergency equipment and medicines were now stored safely and were easily available in an emergency and medicines we checked were all in date. Prescription stationery was kept securely and monitored.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We received no specific feedback from people regarding their experiences for this quality statement. Care home representatives gave examples where practice leaders had acted on feedback to improve safety and efficiency. A representative from the Patient Participation Group (PPG) told us the practice took most suggestions and feedback on board. For example, the practice website had been improved following feedback.

Staff told us they knew how to identify and report concerns, safety incidents and near misses. They told us they learned and made improvements when things went wrong and shared examples of incidents and complaints, learning and improvement. Staff confirmed they could attend regular meetings, held face to face and via a video link, and minutes were available for those unable to attend. Staff told us they were able to raise concerns when things went wrong and were positive about the learning culture within the practice.

The provider had processes for staff to report, record and manage any safety events in a timely way. They had a significant events policy, a duty of candour policy and a reporting process for staff to raise concerns. There was a system to record and investigate complaints, and when things went wrong staff apologised and gave people support. We saw evidence of learning and dissemination of learning to all staff. Minutes of meetings were taken which demonstrated a formal approach to managing learning. Learning from incidents and complaints resulted in changes that improved care for others.

We received mixed feedback from people which related to the management of test results and referrals. Care home representatives confirmed people who had recently moved into a care home were registered with the practice and received a timely health check and medication review by a clinician. They gave positive feedback in relation to timely, appropriate referrals being made and liaison following a hospital discharge.

Staff told us they had the information they needed to deliver safe care and treatment. Reviews were undertaken by practice leaders to ensure that systems and pathway guidelines were adhered to. Staff who were involved in making referrals were clear about their role and daily checks were in place to ensure referral requests had been actioned. A weekly report was completed to check people who had been referred for suspected cancer had attended their appointment and follow up arrangements were in place. Staff were given protected time to ensure this was completed. Arrangements were in place to ensure that when a clinical colleague took leave their tasks were appropriately delegated and shared with appropriate staff.

We received positive feedback from partners in relation to ensuring safe systems of care, including when people were receiving care and treatment from a range of services.

Protocols were in place to manage the flow of work within the practice, which included for example, a care navigator handbook and specific guidance on summarising. There was documented oversight of the work of each team which was updated weekly. This included for example, the number of tasks awaiting action and oldest date for registrations, summarising, coding, prescribing and referrals. This was monitored to ensure people’s correspondence was dealt with in a timely way, to ensure staff in all departments worked within safe limits for completion of work, and to identify if any departments needed additional support. Arrangements were in place for staff to support the work of other teams, as needed. We reviewed the task lists on the clinical system which showed these actions were managed in a timely manner. There was a documented approach to the management of test results, which was managed in a timely manner. Referrals to specialist services were documented, contained the required information and there was a system to monitor delays in referrals. The practice had further improved their referral system with additional checks completed when a clinician had used the words refer or referral in a person’s consultation notes. The practice had a fail-safe system and process to ensure all cervical cytology results were received from samples sent.

People who provided feedback for this assessment had no specific views or concerns in this area.

Staff feedback highlighted the practice had many people registered who were vulnerable with additional complex needs. This included, for example, people for whom English was not a first language, people who were homeless, asylum seekers and refugees. Staff told us they had a high number of safeguarding cases for their practice population. Staff were aware of the practice and local safeguarding policies, had received training, knew who the practice safeguarding leads were, and how to report any concerns. Staff confirmed they attended regular meetings where safeguarding discussions took place.

We received positive feedback from partners on how the practice’s proactive approach to safeguarding kept vulnerable people safe. This included their engagement with safeguarding work and focus on partnership working, supporting other practices with safeguarding, and the openness of practice staff to learn and act on recommendations. An external partner gave an example of when practice staff, which included their domestic abuse champion, went above and beyond to safeguard a person.

The practice had clear systems, practices and processes in place to keep people safe and safeguarded from abuse. These were clearly communicated to staff. There were system alerts to identify vulnerable people on their medical records. The practice had clinical and non-clinical leads, who supported the practice and other practices in the area. All staff had received training in safeguarding children and safeguarding adults to the appropriate level for their role. The practice held regular safeguarding meetings to discuss and review people with safeguarding needs. Practice staff and external partners such as social workers and health visitors attended.

Most people spoke positively about how the practice ensured care met individuals’ needs and enabled them to do things that mattered to them. Care home representatives told us practice clinicians involved people, their carers and family, as appropriate, to ensure care and treatment met individuals’ needs and preferences.

Staff told us there was an effective approach to managing staff absences and busy periods. This had been improved with the successful recruitment of clinical and non-clinical staff. They told us emergency equipment and medicines were easily available and they were routinely checked. They confirmed they had received additional training such as recognising people who may have symptoms of deteriorating health. Staff gave examples of when they had supported people who were distressed, by talking to them on the telephone, whilst clinical help was being sought.

There were effective arrangements for supporting people to identify manage and mitigate risks. The practice had guidance for staff to identify and escalate risk to an appropriate clinician and staff had also received appropriate training. The majority of staff had completed basic life support and anaphylaxis training relevant to their role. Staff who needed to complete this training for example, new staff, were booked onto a course in January 2025. The practice had completed a significant event analysis which related to managing an emergency situation. An improvement action had been completed. The practice had a duty GP and a supervisory GP available every day who were available for advice and support as necessary.

There was a long-standing plan for the practice to move into a purpose built building, however this had been withdrawn recently. Alternative options were being discussed with the Integrated Care Board (ICB). Practice leaders were in the process of reviewing the safety related action plans, as a previous decision was made not to complete some of the recommendations due to the planned move. They confirmed once the estates proposal was confirmed, necessary recommendations would be implemented. Staff told us there were systems, practices and processes to keep people and staff safe. Staff had suitable and sufficient equipment to undertake their role. Some staff gave examples when practice leaders had taken action to ensure their safety, for example installing a light in the car park.

As part of the inspection, we visited the 3 sites used by the practice. Fire exits were clear and fire safety equipment easily available and checked by an external company. We reviewed a sample of electrical equipment which had been tested within the previous year. We reviewed a sample of recommendations identified in risk assessments completed for each site and found these had been actioned.

The practice used risk assessments to identify, manage and mitigate risks. We reviewed a sample of risk assessments which included health and safety, fire and pregnancy. Issues identified from risk assessments and safety checks were shared and discussed with the GP Partners and management team. Most recommendations had been acted on, however where recommendations had not been completed this was documented and monitored. Checks of electrical safety and equipment calibration were also completed. The practice had arrangements to ensure business continuity in a range of circumstances. Practice leaders had arrangements to consider the safety of staff, for example, the rota at 1 of the sites had been amended to ensure staff were not working alone on the first floor. They were also looking into obtaining safety alarms for lone workers completing home visits. The practice used technology securely and effectively and conformed to relevant digital and information security standards with arrangements in place for the confidentiality of data management.

Feedback from people was mainly positive in relation to the knowledge, skill and competency of clinical staff. Representatives from 3 care homes were positive about the knowledge of clinical staff and the clinical care provided.

Practice leaders had successfully recruited 5 new salaried GPs in 2024 and were now clinically fully staffed with GPs. GP Partners had implemented a gradual reduction in the use of locum GPs, to minimise the impact of this change to people using the service. There were on going plans to recruit a receptionist, practice nurse and health care assistant to meet the demands of the growing practice population list. Most staff told us there were sufficient staff. Staff told us there was an effective induction system for permanent and temporary staff tailored to their role. Staff who were responsible for specific clinical interventions, for example reviews of people with long-term conditions, cervical screening, and childhood immunisation, told us they had received specific training. Staff received regular appraisals, and their development and training was discussed in their appraisal. Staff were supported by their peers, team leaders, clinical and management leads.

The practice had clear systems and process for safe recruitment. We reviewed 2 staff personal files and found appropriate recruitment checks had been carried out, which included Disclosure and Barring (DBS) checks. All new staff received an induction programme which included a visit to all sites. The professional registration of clinical staff was checked at recruitment and on an ongoing basis. There was a system to monitor the completion of training deemed mandatory by the practice. All staff had completed mandatory training which included for example, equality and diversity, information governance, fire safety and health and safety. All staff had undertaken learning disability and autism awareness e-learning and were in the process of completing the face-to-face element of this training. The practice was able to demonstrate that staff had the skills, knowledge, and experience to carry out their roles. Staff who were responsible for childhood immunisations and cervical screening had received specific training. The practice demonstrated they had clinical oversight of the prescribing competence of all clinicians. There was a regular review of their practice supported by clinical supervision or peer review, audits, and protected time for case review. There was a supervisory GP available, in addition to the duty GP, for clinical advice and support. Audits were also completed for oversight of the work of salaried and locum GPs and GP partners. There was oversight of the completion of staff appraisals. The majority of staff had already received an appraisal, and other staff had these booked. To ensure sufficient staff were available, the practice minimised the number of staff who were off work at any one time. Some staff were multi-skilled and worked flexibly in response to peak times of demand from people using the service, and to minimise the impact of unexpected staff absence.

The majority of people did not give feedback on this quality statement; however, we received negative feedback from 1 person regarding their experience for this quality statement. Feedback we received from care home representatives was positive in respect of the cleanliness of the environment and infection prevention and control measures undertaken by staff.

Staff were aware of the Infection, Prevention and Control (IPC) policy and procedures, the IPC lead and had no concerns about the IPC processes in place at the 3 sites.

We visited the 3 sites and reviewed a sample of actions identified from the IPC audit. Some actions had been completed, for example, mops were stored inverted and were colour coded with a poster displaying the colour code. A cleaning schedule for the vaccine fridge was available and cleaning was documented. Some actions had not been completed, for example the plumbing under sinks was uncovered and clinical hand wash basin brackets and fittings were not concealed. Practice leaders were aware of this and advised this work and redecoration had been put on hold due to the planned new build, which had recently been withdrawn. They confirmed once the estates proposal was confirmed, necessary recommendations would be implemented. We found the external clinical waste bins were locked at 3 sites; however, they were only secured at 1 site. The practice took immediate action to address this and submitted evidence that these had been secured, following the site visit.

A range of policies and procedures were in place for IPC. There was a clinical lead for IPC who had protected time to undertake their role. An external IPC audit was undertaken at each site and an action plan was in place. There were bi-monthly IPC business meetings where IPC issues were discussed, and actions agreed and monitored. For example, the replacement of damaged chairs. All staff had completed IPC training. The practice used the same external cleaning company across the 3 sites. Cleaning schedules were in place. There was a record of cleaning and oversight of the cleaning completed by both the company and the practice. Arrangements were in place to effectively resolve any issues.

Most people were involved in regular reviews of their medicines and received good advice and quick responses to any medicine and prescription queries. However, we also received feedback which related to poor communication regarding changes to medicines and the management of repeat prescriptions. We received feedback from care home representatives who told us the repeat ordering process generally worked well and staff answered and dealt with any queries effectively. They told us people’s medicines were reviewed and there was appropriate liaison with other services.

Staff were confident managing the storage, checking, administration and recording of medicines. Staff gave an example of action taken when a breach in the cold chain had been identified. Prescription teams meetings were held where any issues or suggestions were discussed. The prescription team lead attended team leads meetings where issues were shared, and actions agreed across teams. Staff told us they involved people in reviews of their medicines and helped them understand how to manage their medicines safely. Staff told us they followed practice policies and protocols to ensure they prescribed medicines safely, and ensured people received recommended medicines reviews and monitoring. The practice employed 2 Clinical Pharmacists, who supported with medicine reviews. GP Partners had identified and had planned to increase the amount of written commentary in their general medication reviews. Staff informed people who to contact if their condition did not improve or they experienced any unexpected symptoms. Staff told us regular searches and audits were in place to support the practice to deliver timely and effective medicine reviews. For example, an audit identified compression stockings were not being correctly prescribed. A change was made so only practice nurses and health care assistants who had been trained, assessed for compression stockings and then advised the prescriber.

During our onsite visit to the 3 sites, we observed arrangements were in place to manage medicines safely. The practice held appropriate emergency medicines and equipment at the 3 sites. There was a system in place to monitor stock levels and expiry dates of all medicines, including emergency medicines and vaccines. These were checked on a regular basis and documented. Medical gases, such as oxygen, were stored safely with appropriate signage in place. Vaccines were appropriately stored, monitored, and transported in accordance with national guidelines and medicines that required cold storage were being appropriately kept within temperature monitored fridges. Immediate arrangements were in place if temperatures went out of range. The practice did not keep Controlled Drugs at any of the sites. Prescription stationery was stored securely, however the system in place to monitor prescription stationery was not effective. The practice took immediate action to address this and submitted an updated protocol following the site visit.

Processes were in place to ensure the prescribing competence of non-medical prescribers, there was regular review of their prescribing practice. Patient Group Directions (PGDs) were in place to allow nurses to give vaccinations without a prescription and these had been appropriately authorised for use within the service. Our clinical searches showed systems to review medicines which required additional monitoring were safe. We identified 110 people who were prescribed a specific medicine, 33 people had not had the required monitoring in the last 12 weeks and 1 person in the last 6 months. System alerts were in place to alert when people were overdue the 12-week monitoring time and were acted on by the practice. On the day of the site visit, all people had received the required monitoring. Another clinical search identified 116 people with heart failure prescribed a medicine which needed monitoring. 8 people had not had their medication monitored. We reviewed the records of 5 people: 4 people had been recalled and 1 person had not. We raised this with the GP partners who reviewed this and advised the medication dose was outside of the parameters of the recall criteria and immediately amended this. There were effective systems to manage and respond to safety alerts and medicine recalls. Our clinical searches showed good care for people although some processes required review. For example, medicine which, when taken by women of childbearing age, must have counselling and a documented pregnancy prevention plan (PPP) in place. We raised this with the GP Partners who agreed to identify and review people who should have this in place. In response, the practice had clinically prioritised people for review. All people had been contacted and 23 out of 29 people identified had a review appointment booked. Arrangements were in place to continue to follow up the other 6 people.

Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes. Most of the prescribing data reviewed as part of our assessment confirmed this. However, the number of antibacterial prescription items prescribed was above the local and national averages. The practice were aware of this and undertook regular audits of prescribing staff to ensure medicines were prescribed in line with current guidance. Feedback was given to staff as appropriate following the audits. The practice believed this prescribing would reduce with 5 new salaried GPs who had been employed recently. There was a programme of auditing of prescribing of all clinical staff who prescribed that focused on improving care and treatment.