Alum Rock Medical Centre

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• 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 8 quality statements for this key question (Learning culture; Safe systems, pathways and transitions; Safeguarding; Involving people to manage risks; Safe environments; Safe and effective staffing; Infection prevention and control and Medicines optimisation).

We found safety systems and processes were in place and evidence of learning following complaints and incidents. However, not all were effective or well embedded. For example, safeguarding, recruitment processes, systems to manage infection prevention and control (IPC), medicines and quality of record keeping required improvement.

The provider was keen to improve and was responsive to feedback when we raised concerns with them.

We found breaches of the legal regulations in relation to providing safe care and treatment and good governance. Systems were not effective in identifying, mitigating and monitoring risk related to patients and staff. This included safeguarding and, recruitment processes, ongoing monitoring of training, medicines management and infection prevention and control.

We have asked the provider for an action plan in response to the concerns found.

This service scored 50 (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 an active Patient Participation Group (PPG). Members that we spoke to were positive about leaders working with them to improve services.

When we reviewed the practice website, we saw that the last Patient Participation Group meeting minutes were from 2017.

When people left comments or reviews on the NHS and Healthwatch websites, the practice did not respond. Leaders told us they did not monitor this information. This was a missed opportunity for the practice to gather and respond to people’s feedback, and take action to improve the service.

We received complaints to CQC that indicated when people requested to speak to someone about their complaint, staff had not contacted them back and when people did complain formally they did not get a response.

Staff had opportunities to raise concerns and learn from incidents and complaints. Staff felt supported to raise concerns and shared examples where the practice had contacted patients to explain when something had gone wrong.

If staff were not able to attend meetings, information relating to complaints and incidents was available to all staff electronically.

The practice had received 6 written complaints in the 12 months leading up to the assessment. From information we reviewed relating to these 6 complaints, we saw that the practice had contacted people who had complained to provide them with a response and that complaints and outcomes were discussed in monthly practice meetings.

The provider had processes for staff to report incidents and safety events. There was a system to record and investigate complaints. However, the system required improvement.

There was evidence that learning from incidents and complaints resulted in changes, however, the provider could not demonstrate that actions had led to sustained improvements. Leaders told us they met to discuss trends and patterns in incidents and complaints, however, records of these meetings were not kept to evidence actions they had taken.

The Patient Participation Group (PPG) met 6 monthly. There was evidence that there was learning and improvements made following engagement with the PPG.

We looked at 2 complaints in detail and found that while people received a final response to their complaint, they did not receive an initial acknowledgement in line with the provider’s policy.

We found that information for patients on how to complain had not been updated.

The provider’s complaints policy did not give sufficient guidance to staff for example when and how trends would be analysed, where information should be stored, or how learning would be discussed with other staff.

The significant event policy had been reviewed in May 2023. The policy did not say who the lead was for managing significant events.

The form used to record and analyse significant event information did not prompt staff to question if the incident needed to be raised externally. We saw however, that there was reference to this in the significant event policy itself.

When negative comments were left through the Friends and Family Test, the practice discussed the comments and how to improve the service in practice meetings.

Leaders had met to discuss the results of the 2024 National GP patient survey, however no action plan had been formed, other than to conduct their own patient survey.

Patient feedback we reviewed from complaints to CQC about the service and comments left on the Healthwatch website indicated that referrals to other services were not always made in a timely manner.

We also received a complaint that indicated the practice had not reviewed its patient list to ensure they only registered patients that they could provide home visits to if these were indicated or kept patients aware of the geographical area that they provided home visits to.

Staff described efficient processes which ensured that test results and communication from external organisations was processed and actioned in a timely manner. Workloads were managed and distributed equally across the staff.

Staff communicated within the practice and with external organisations when needed to keep people safe and ensure continuity in care.

Clinical staff were able to seek support from GPs when needed.

We found that historically (under the previous GP partners) safeguarding codes had not always been used, this meant that when patient’s moved practice, any safeguarding concerns may not have been passed onto the new practice. Staff told us they were taking action to amend records and contact relevant GP practices.

We did not receive any feedback from partners in relation to this evidence category.

Our review of patients’ records and the clinical system indicated that letters, referrals and blood tests results were managed and responded to safely . The provider could mostly demonstrate that all communication was reviewed and acted on appropriately. We found an example where a patient had been reviewed by the hospital and then reviewed by the practice, however staff had not updated the patient’s record to demonstrate that these blood test results were reviewed. We did not identify any safety concerns for that patient and the provider told us they would amend their processes. We found 2 examples where a medicine review had been completed by the hospital, however on receipt of the letter, the practice had not updated the patient’s record to reflect this medicine review had taken place.

Our record reviews indicated that clinical staff escalated concerns to GPs when needed.

The provider used an external organisation (clinical pharmacists) and non-clinical practice staff to help manage letters from external organisations and the coding of medical records. The provider told us of their system to audit and monitor those actions taken by the clinical pharmacists, however they did not monitor actions taken by non-clinical staff. We found that while records had been updated correctly following receipt of a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) form, there was no prompt to GPs to review the form when the patient changed care setting, for example from hospital to home.

We found the practice had effective processes for registering new patients and summarising their records. However, there was no process for monitoring how many records were awaiting collection when patients had de-registered from the practice.

The practice had processes in place to monitor that a result had been received for every cervical screening sample sent off for analysis.

The practice had processes in place to monitor urgent (2 week wait) referrals that had been made.

We could not collect any evidence from patients to score this evidence category, however, our observations raised concerns regarding safeguarding at the service. We raised our concerns with the provider.

The practice had a lead for safeguarding. All staff we spoke with were aware of who the lead was.

The safeguarding lead had support from non-clinical staff to update patient’s records. Non-clinical staff had 5 hours a month to update records and registers with safeguarding information.

Clinical staff sent tasks to administrative staff if updates to patient records were needed.

Staff told us they had opportunities to discuss safeguarding concerns during practice meetings.

Staff told us historically, clinical staff used free text within records instead of using codes, when reporting on safeguarding issues or concerns. The provider could not demonstrate that all patient’s records were coded correctly or that staff were discussing these patients regularly or removing them from the registers as appropriate.

Not all chaperones we spoke to were aware of their roles and responsibilities.

We did not collect any evidence from partners to score this evidence category.

Our observations raised concerns regarding safeguarding at the service. We raised our concerns with the provider.

The provider had not implemented effective systems and processes to manage safeguarding.

Safeguarding registers were not accurate and patient records had not been coded correctly. The practice had systems in place to alert staff to which patients were vulnerable, however, because records had not been coded correctly historically, staff were not always alerted. If records are not coded correctly, safeguarding concerns would not be identifiable when patients changed to a new practice.

Safeguarding leads had not categorised patients according to risk level so that they could be monitored accordingly.

Not all relevant staff were able to find safeguarding registers.

When safeguarding concerns where identified, records of people who lived in the same household were not updated or linked to reflect these concerns.

Policies were in place and accessible to staff, however, they did not include up- to -date training requirements in line with intercollegiate guidance.

The chaperone policy was not appropriate and indicated that the chaperone may be a family member or friend.

The Recruitment and selection policy was not being followed. Not all staff had received a Disclosure and Barring Service (DBS) check. 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.

The safeguarding lead for children and adults was not up-to-date with required training.

We saw that safeguarding concerns were discussed in monthly practice meetings and leaders told us they held multidisciplinary meeting every 6 months. However, the last safeguarding meeting was held in February 2024 and no further meetings had been held since to ensure information sharing, collaboration and improved outcomes for vulnerable patients.

When we reviewed the safeguarding registers we found that no patients had been identified at risk of/had experienced female genital mutilation.

Patient feedback was mixed.

From complaints received into CQC we found that patients did not always feel supported to manage risk or to understand their condition and the reason for a particular treatment.

Data from the 2024 National GP patient survey showed that 87% of people that responded to the survey felt they had been involved as much as they wanted to be in decisions about their care and treatment. This was similar to local (89%) and national averages (91%).

The practice had carried out their own in-house patient survey in August 2024. We saw that feedback was positive about being involved in decisions about their care. Of the 40 people who responded 38 said they felt they were involved in decisions about their care and treatment.

Patients were informed about any risks and how to manage their medical condition. Staff would use alternative methods of communication where needed and had access to interpreters.

Staff met with patients and/or their families and carers to discuss their care and treatment.

From our record reviews we found that care plans were completed with patients and their carers. Reviews of long-term condition records indicated that reviews were thorough and patients were given safety netting advice to deal with risks that may occur.

We reviewed a sample of patient records for patients with a learning disability. Of those records we viewed, we saw that all patients had carers involved where appropriate. All patients were reviewed face-to-face. There was evidence of documented shared decision making.

However, we did find that people recently diagnosed with Type 2 diabetes, their records had not always been coded correctly. We viewed a sample of records and found that in 2 out of the 5 records we reviewed, a discussion had not been held with the patient to discuss their diagnosis and management plan. The provider took immediate action to contact patients, update their records and sent communication out to staff to remind them about coding records following a diagnosis.

The premises were 2 houses that had been converted.

Staff told us that clinic rooms were all on the ground floor. The first floor was not used by patients.

The building was owned by the provider and they had responsibility for maintenance of the building and grounds. The provider was aware that the building required renovation and told us they were in the process of obtaining quotes to carry out the renovations, however there were no confirmed dates for when building work would start.

Staff told us they had processes in place to request repairs however certain repairs or upgrades to the premises or equipment were on hold and would be completed as part of the planned renovations. We saw this was recorded on the provider’s risk register.

We found concerns with the premises and equipment during our onsite inspection.

The building was not well maintained. As well as requiring general re-decoration, we found that flooring in reception had been repaired with tape which was peeling and torn in places.

The reception desk was not accessible to wheelchair users.

There was paint peeling off the wall under the stairs.

A wall in the nurses room was damaged and required repair.

Reception staff did not have suitable workstations.



The fire evacuation assembly point was at the back of the building, we saw there was a flight of stairs down from the rear entrance and this was not accessible to all patients with mobility issues. The front access was accessible however there was no access to the meeting point from the front of the building.

In the main patient toilet, we found there was a door that led to a storage cupboard that was unlocked and used to store clean sharps bins as well as other items.



Clinic rooms had appropriate flooring and equipment.

Appropriate emergency equipment and medicines were in place and accessible to staff.

However, we found out of date syringes and one out of date emergency medicine that had not been disposed of.

The disabled toilets had an emergency pull cord however this was tied up and would not be accessible in the event of an emergency.

Processes to identify, mitigate, monitor and manage risks related to the premises were not always effective. Not all risks had been identified or considered and where risks had been identified there were not always clear actions to mitigate them..

The practice carried out fire drills annually and no issues had been identified during the drills. However, during the assessment, staff were not able to tell us how they would safely manage people leaving the building using the different exits.

2 non-clinical staff had not completed appropriate training in fire safety and completion of basic life support training was not being monitored in line with practice policy.

There were systems in place to communicate with the cleaning staff and staff had access to spot checks undertaken and deep cleaning records. However, the provider could not demonstrate how they ensured that cleaning was undertaken by practice staff of their individual clinical areas and equipment. We saw that this was an action following the infection prevention and control audit in 2022.

There were processes in place to check that electrical equipment was safe.

The practice had carried out an accessibility audit in 2017, however, this had not been reviewed since.

We saw 3 different action plans for infection prevention and control. One of the plans did not have a date on it to indicate when the plan was created. We saw that risks identified in February and April 2024 were still ongoing at the time of the on-site visit and action was not planned to be completed until December 2024.

We saw 4 workstation assessments for non-clinical staff. We found that 2 of these assessments had been completed after our site visit and 2 staff had identified issues with the workstations and equipment and 2 staff had reported suffering health issues as a result of using the computer at work. We did not see evidence of action being taken to support staff.

CQC received complaints about non-clinical and clinical staff. People complained that staff were not always trained appropriately to respond to immediate queries and appointments were not always booked with the most appropriate clinician that met their clinical needs.

Of the people that responded to the 2024 GP patient survey, 85% had confidence and trust in the healthcare professional they saw or spoke to during their last general practice appointment. This was lower than local (90%) and national average (92%).

Leaders told us about the processes in place to provide regular clinical supervision and/or support to staff in clinical roles including non-medical prescribers and physician associates.

All staff we spoke with told us they had access to support when they needed it and they felt supported to develop professionally.

Staff told us they received an appropriate induction and ongoing training that was relevant to their role.

Staff told us they received appraisals and had time to complete mandatory training.

The practice ensured they had the right number of staff and skill mix to support delivery of services. However, the practice nurse worked one day a week and routine GP appointments were with female GPs. We found this limited patient choice.

Workforce data published by NHS England showed that the number of patients per Full-Time Equivalent (FTE) nurse was greater when compared with the national average.

The practice did not have effective systems in place to monitor that staff were up to date with required training in line with recognised guidance or their own policies.

Not all staff had completed appropriate training in safeguarding, fire, basic life support or learning disability and autism.

The system in place for monitoring staff training did not alert leaders when training was overdue. Following our assessment the provider sent us updated information confirming this had been actioned.

From staff files we reviewed we found induction paperwork was not complete and relevant immunisation information was not always collected.

One staff member had not completed the required training to administer vaccines and competency paperwork had been completed retrospectively. We acknowledged this was before the current GP partners took the practice over, however, they were not aware. On becoming aware, they took immediate action to arrange training for this staff member.

We found recruitment processes were not well embedded. Enhanced Disclosure and Barring Service (DBS) checks were not always carried out for staff where needed. Enhanced 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.

During our record reviews, we did not find any concerns in the quality of the reviews carried out by the healthcare assistants. However, we did find that records had not always been coded correctly. There was no oversight of this by leaders.

We received a complaint about the area in the practice where some vaccinations were being delivered from, lack of staff training in regard to infection prevention and control (IPC) and the IPC processes at the practice including the clinical area and equipment that was being used.

Staff told us they had a good relationship with the cleaning staff and they were able to raise concerns with them about the quality of cleaning.

Staff were aware of the issues with the premises including general decoration, furniture that needed replacing and the wall in the nurses room that needed repair. Staff told us these issues had been raised with management. They told us the wall had been repaired previously however the problem had arisen again and required more significant repairs.

Staff told us the plan for IPC was continuously being worked on.

There was confusion amongst staff about who the lead for IPC was.

We observed that not all areas of the practice were visibly clean; window blinds throughout the practice and an extractor fan in a clinical room were dirty.

There were old stains on the walls in reception and the flooring in reception was broken in parts with hazard tape across it, that had also worn away or torn. There were old COVID19 distancing stickers that were worn and had partially peeled off.

The building, in particular, the reception area required re-decoration. We saw there was paint peeling off under the stairs near the patient accessible toilet.

Vaccine fridges were suitable and not overfilled; the temperature of these was monitored.



We found that a sharps bin was not stored safely in the clinical area, this bin and others we viewed were not signed or dated.

Personal protective equipment (PPE) was available in all the clinic rooms we inspected.



We saw that clinical waste awaiting collection was not labelled in line with regulations. This had been identified as a concern on the April 2024 IPC audit, the action had been marked as completed in November 2024.

We saw one of the toilets had a wooden seat. We saw this was logged on the risk register as needing replacement however not because it was an IPC concern but because it would be uncomfortable.

There were no cleaning schedules or arrangements in place for staff to clean their rooms and equipment in between patients and/or at the end of the day. We saw this had been identified on previous IPC audits and action plans.

The infection prevention and control (IPC) policy had been implemented in February 2024. The policy was not comprehensive and did not give sufficient detail on how to manage IPC effectively.

The practice did not have effective IPC monitoring and audit systems.

The in-house audit from April 2024 showed 95% compliance with IPC standards.

We saw 3 different action plans for IPC. The 2022 IPC action plan showed no comments or dates to indicate that actions had been completed. Many of the issues we found during our site visit were listed on this action plan, this would indicate that actions either were not taken or were not effective.

We saw that risks identified in February and April 2024 were still ongoing and action was not planned to be completed until December 2024. Not all actions from the April 2024 audit were on the action plan.

During the site visit we were told the legionella risk assessment had not been repeated since 2017. We were however sent evidence, following the site visit, of a more recent assessment in July 2024. It was not clear if bathrooms on the first floor had been considered and we were not sent evidence of action that was taken regularly to mitigate risk.

The provider did not have effective processes to monitor that staff had completed the correct level of IPC training for their role or that staff had completed sepsis training.

The provider did not have effective systems in place to collect and record information relating to staff immunisations.

Records to evidence that cleaning had taken place were kept up to date. However, processes to monitor that cleaning by the cleaning company met IPC standards were not effective.

Before the site visit, we had contacted the provider about concerns we had received about patients receiving immunisations in an area that was not appropriate. While the provider had taken immediate action to respond to our concerns, they could not demonstrate that they had adequately assessed the area for its suitability.

We received concerns about prescriptions, that they were not always signed or given by authorised people. We discussed these concerns with the provider before and during the assessment. The provider gave us assurances that they were aware of concerns and changes to processes had been made so that prescriptions were only authorised by clinicians with the correct authority.

Feedback from the Patient Participation Group was that they had had helped to make improvements to medicines management processes.

Staff told us people were involved with assessments and reviews about the level of support they needed to manage their medicines safely and to make sure their preferences were included.

Staff felt confident managing the storage, administration and recording of medicines. Staff followed protocols to ensure they prescribed all medicines safely, and ensured people received recommended medicines reviews and monitoring.

Staff and leaders described the processes they had implemented to ensure that medicines and treatments were safe and met people’s needs.

However, during the assessment we found concerns with the processes the provider had implemented as detailed below.

We found one emergency medicine that had expired the month before the assessment and had not been disposed of correctly.

Other emergency medicines we checked were in date and stored appropriately, with access given to appropriate staff. Emergency medicines were accessible to staff in the event of an emergency.

Blank prescription stationery was kept securely.

Staff mostly managed medicines safely, however some processes required improvement.

The practice had systems in place to receive, share and act on safety alerts.

There were effective processes in place to respond to blood test results and correspondence from external organisations when changes to medicines were required.

There was evidence of effective medicines reviews for patients on repeat medicines.



Leaders carried out regular medicine prescribing audits to ensure that care and treatment was in line with national guidelines. The practice had not repeated their antibiotic audit since June 2022. However, we did not identify any concerns with antibiotic prescribing during this assessment.

The practice did not have effective processes in place to review and monitor that staff had the correct training and authorisation to administer vaccinations and medicines.

Patient group directions (PGDs) we viewed were not all signed and dated correctly.

We saw that the PSD policy was a new policy and had been introduced 2 weeks before the assessment. The policy was not being followed at the time of the assessment. The provider told us, following the onsite visit, they had taken immediate action to ensure staff were following the policy.

Our record reviews and review of the clinical system indicated that care records were mostly managed in a way to protect patients. For example, in records we viewed information on history, examination, management plans, safety netting and follow up were adequately documented within the patient record. We found that overall patients’ treatment was monitored in line with guidelines. We identified some gaps in records but did not see this has impacted on patient’s care or treatment and discussions with leaders demonstrated appropriate action had been taken.

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 and we saw that antibiotic prescribing had reduced since 2022 to expected levels.