The Care Quality Commission (CQC) are the independent regulator of health and adult social care in England.

The CQC make sure health and social care services provide people with safe, effective, compassionate, high-quality care and encourage them to improve.

They monitor, inspect and regulate services to make sure they meet fundamental standards of quality and safety and publish what is found, including performance ratings to help people choose care.

Our GP Practice has recently undergone a CQC inspection and the results are now freely available on the CQC Website.

The Results were:

Safety – Good

The practice is rated as good for providing safe services. Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Lessons were learned and communicated widely to support improvement. Information about safety was recorded, monitored, appropriately reviewed and addressed. The practice had robust systems to deal with emergencies and had a comprehensive business continuity plan in place.
Risks to patients were assessed and managed, however the practice did not have oversight of all the risks relating to the day to day running of the practice. For example in relation to areas such as conducting and documenting regular health and safety checks and risk assessments for manual handling.

Effectiveness – Good

The practice is rated as good for providing effective services. Data showed patient outcomes were generally better than the average for the locality. For example, the practice performed best within the local area in respect of the lowest rate of emergency admissions between June 2014 and May 2015. Staff had access to local and national guidelines and used these routinely to plan and deliver patient care.
We saw evidence of effective multidisciplinary working and feedback from external stakeholders was very positive.
Staff had received training appropriate to their roles and any further training needs had been identified and planned to meet these needs. Staff told us they had received appraisals in the last 12 months and computer records showed the dates these had been held, however records of appraisals were missing at the time of the inspection.

Caring – Good

The practice is rated as good for providing effective services. Data showed patient outcomes were generally better than the average for the locality. For example, the practice performed best within the local area in respect of the lowest rate of emergency admissions between June 2014 and May 2015. Staff had access to local and national guidelines and used these routinely to plan and deliver patient care.
We saw evidence of effective multidisciplinary working and feedback from external stakeholders was very positive.
Staff had received training appropriate to their roles and any further training needs had been identified and planned to meet these needs. Staff told us they had received appraisals in the last 12 months and computer records showed the dates these had been held, however records of appraisals were missing at the time of the inspection.

Effectiveness – Good

The practice is rated as good for providing effective services. Data showed patient outcomes were generally better than the average for the locality. For example, the practice performed best within the local area in respect of the lowest rate of emergency admissions between June 2014 and May 2015. Staff had access to local and national guidelines and used these routinely to plan and deliver patient care.
We saw evidence of effective multidisciplinary working and feedback from external stakeholders was very positive.
Staff had received training appropriate to their roles and any further training needs had been identified and planned to meet these needs. Staff told us they had received appraisals in the last 12 months and computer records showed the dates these had been held, however records of appraisals were missing at the time of the inspection.

Leadership – Good

The practice is rated as good for being well-led. It had a clear vision and strategy. Staff were clear about the vision and the practice values and their responsibilities in relation to this.
There was a clear leadership structure and staff felt supported by management and their colleagues. The practice had a number of policies and procedures to govern activity and held regular governance meetings. There were systems in place to monitor and improve quality and identify risk. The practice proactively sought feedback from staff and patients, which it acted on. The patient participation group (PPG) was active and had been involved in the design of the new practice building. Staff had regular access to training and attended staff meetings and events.

Please find attached Musters Medical Practice chaperone policy

Musters Medical Practice chaperone policy

Practice Complaints Procedure

Patient feedback is important to us as it helps us to improve the service we provide to patients. We take patient complaints seriously and will attempt to address your concerns to your satisfaction.

How do I make a complaint?

If you wish to complain please contact the Practice Manager Emma Strzelec either in person, by phone or in writing:

Tel: 0115 9814124

Address: 50-60 Wilford Lane, West Bridgford, Nottingham NG2 7SD

Online:

Patient-Complaint-Form

Third-Party-Patient-Complaint-Form

If you are complaining on behalf of someone else, the practice needs to know that you have their permission to do so.

What Happens Next?

The complaint will be acknowledged within 3 working days.  The practice will respond, after investigation, within the timeframe specified to you at the acknowledgement stage of the process.  Some complaints may take longer to address but you will be informed of a response time.  If this cannot be met, the practice will keep you informed.

Please be assured making a complaint will not adversely affect your ongoing healthcare at the practice.  We will deal with you fairly, compassionately and will endeavour to resolve the situation to a satisfactory conclusion.

Wherever possible, we aim to learn from complaints and take action to avoid similar occurrences.

Third Party Complaints

We allow third parties to make a complaint on behalf of a patient. The patient must provide consent for them to do so.  A third-party patient complaint form is available from reception or our practice website.

How do I complain to someone Independent?

GP Practices would prefer to have the opportunity to answer complaints ourselves in the first instance. However, you may pass your complaint directly to:

Patient Experience Team

Nottingham and Nottinghamshire Integrated Care Board

Sir John Robinson House

Sir John Robinson Way

Arnold

Nottingham

NG5 6DA

Tel: 0115 8839570

Email: nnicb-nn.patientexperience@nhs.net

If you would like further information, please follow the link to the ICB website:

Patient Experience and Complaints – NHS Nottingham and Nottinghamshire ICB

However, please note, patients cannot raise the same complaint with the practice and ICB.

Is there a time limit?

A complaint must be made within 12 months of the date of the incident that caused the problem or the date of discovering the problem.

Please remember, the sooner you provide the Practice with the information, the easier it will be to investigate the facts.

If you are not satisfied with the outcome?

Further Action

If you are dissatisfied with the outcome of your complaint from either Nottingham and Nottinghamshire ICB or this practice, then you can escalate your complaint to Parliamentary Health Service Ombudsman (PHSO) at either:

Milbank Tower, Milbank

LONDON

SW1P 4QP

Citygate, Mosley Street

MANCHESTER

M2 3HQ

Tel: 0345 015 4033

www.ombudsman.org.uk

Other useful contacts

POhWER, NHS Complaints Advocacy, on 0300 456 2370.  For more information see their website www.pohwer.net

For more information, visit: NHS – How to complain to the NHS

Your Data Matters to the NHS

Information about your health and care helps us to improve your individual care, speed up diagnosis, plan your local services and research new treatments. The NHS is committed to keeping patient information safe and always being clear about how it is used.

How your data is used

Information about your individual care such as treatment and diagnoses is collected about you whenever you use health and care services. It is also used to help us and other organisations for research and planning such as research into new treatments, deciding where to put GP clinics and planning for the number of doctors and nurses in your local hospital.  It is only used in this way when there is a clear legal basis to use the information to help improve health and care for you, your family and future generations.

Wherever possible we try to use data that does not identify you, but sometimes it is necessary to use your confidential patient information.

You have a choice

You do not need to do anything if you are happy about how your information is used. If you do not want your confidential patient information to be used for research and planning, you can choose to opt out securely online or through a telephone service. You can change your mind about your choice at any time.

Will choosing this opt-out affect your care and treatment?

No, choosing to opt out will not affect how information is used to support your care and treatment. You will still be invited for screening services, such as screenings for bowel cancer.

What do you need to do?

If you are happy for your confidential patient information to be used for research and planning, you do not need to do anything.

To find out more about the benefits of data sharing, how data is protected, or to make/change your opt-out choice visit www.nhs.uk/your-nhs-data-matters

All GP practices are required to declare the mean earnings (e.g. average pay) for GPs working to deliver NHS services to patients at each practice.

The average pay for GPs working in Musters Medical Practice in the last financial year was £92,163 before tax and National Insurance. This is for 6 full time GPs who worked n the practice for more than six months.

Purpose

This annual statement will be generated each year in March in accordance with the requirements of the Health and Social Care Act 2008 Code of Practice on the prevention and control of infections and related guidance. The report will be published on the practice website and will include the following summary:

• Any infection transmission incidents and any action taken (these will have been reported in accordance with our significant event procedure)
• Details of any infection control audits undertaken, and actions undertaken
• Details of any risk assessments undertaken for the prevention and control of infection
• Details of staff training
• Any review and update of policies, procedures and guidelines

Infection Prevention and Control (IPC) Lead

The lead for infection prevention and control at Musters Medical Practice is Shelley Herbert (Nurse Manager)

The IPC Lead is supported by Emma Strzelec, Practice Manager

       a. Infection transmission incidents (significant events)

Significant events involve examples of good practice as well as challenging events.

Positive events are discussed at meetings to allow all staff to be appraised of areas of best practice.

Negative events are managed by the staff member who either identified or was advised of any potential shortcoming. This person will complete a Significant Event Analysis (SEA) form that commences an investigation process to establish what can be learnt and to indicate changes that might lead to future improvements.

All significant events are reviewed and discussed in several meetings each month. Any learning points are cascaded to all relevant staff where an action plan, including audits or policy review, may follow.

In the past year (01.02.24 – 28.02.25) there have been 1 significant event raised that related to infection control. This was due to the breakdown of the vaccine fridge. There have been no complaints made regarding cleanliness or infection control.

      b.     Infection prevention audit and actions

Musters Medical Practice received a rating of good following the most recent inspection by the Care Quality Commission in December 2015, it was noted that the practice maintained appropriate standards of cleanliness and hygiene and the premises was observed to be clean and tidy.

Regular audits are carried out and a rolling refurbishment programme is in operation to ensure compliance with all standards.

     c.      Risk Assessments

Risk assessments are carried out so that any risk is minimised to be as low as reasonably practicable. Additionally, a risk assessment which can identify best practice can be established and then followed.

In the last year the following risk assessments were carried out/reviewed:

• General IPC risks
• COSHH
• Legionella
• Staff Vaccination

In the next year, the following risk assessment will also be reviewed:

• General IPC risks
• COSHH
• Legionella
• Staff Vaccination

       d.     Training

In addition to staff being involved in risk assessments and significant events, at Musters Medical Practice all staff receive IPC induction training on commencing their post. Thereafter, all staff receive refresher training annually.

      e.     Policies and procedures

The infection prevention and control related policies and procedures which have been written, updated or reviewed in the last year include, but are not limited, to:

• Infection Prevention Control policy
• Staff Immunisation policy
• Personal Protective Equipment at Work Policy
• COSHH Policy
• Hand Hygiene

Policies relating to infection prevention and control are available to all staff and are reviewed and updated annually. Additionally, all policies are amended on an ongoing basis as per current advice, guidance, and legislation changes.

Responsibility

It is the responsibility of all staff members at Musters Medical Practice to be familiar with this statement and their roles and responsibilities under it.

Review

The IPC Lead and Practice Manager are responsible for reviewing and producing the annual statement.

This annual statement will be updated on or before 1st March 2026

Signed by

Emma Strzelec

Practice Manager

Confidentiality & Medical Records

The practice complies with data protection and access to medical records legislation. Identifiable information about you will be shared with others in the following circumstances:

• To provide further medical treatment for you e.g. from district nurses and hospital services.
• To help you get other services e.g. from the social work department. This requires your consent.
• When we have a duty to others e.g. in child protection cases anonymised patient information will also be used at local and national level to help the Health Board and Government plan services e.g. for diabetic care.

If you do not wish anonymous information about you to be used in such a way, please let us know.

Reception and administration staff require access to your medical records in order to do their jobs. These members of staff are bound by the same rules of confidentiality as the medical staff.

Freedom of Information

Information about the General Practioners and the practice required for disclosure under this act can be made available to the public. All requests for such information should be made to the practice manager.

Access to Records

In accordance with the Data Protection Act 1998 and Access to Health Records Act, patients may request to see their medical records. Such requests should be made through the practice manager and may be subject to an administration charge. No information will be released without the patient consent unless we are legally obliged to do so.

Complaints

We make every effort to give the best service possible to everyone who attends our practice.

However, we are aware that things can go wrong resulting in a patient feeling that they have a genuine cause for complaint. If this is so, we would wish for the matter to be settled as quickly, and as amicably, as possible.

To pursue a complaint please contact the practice manager who will deal with your concerns appropriately. Further written information about the complaints procedure is available from reception.

Violence Policy

The NHS operate a zero tolerance policy with regard to violence and abuse and the practice has the right to remove violent patients from the list with immediate effect in order to safeguard practice staff, patients and other persons. Violence in this context includes actual or threatened physical violence or verbal abuse which leads to fear for a person’s safety. In this situation we will notify the patient in writing of their removal from the list and record in the patient’s medical records the fact of the removal and the circumstances leading to it.

Musters Medical Practice – Privacy Policy

How we use your personal information

This Privacy Notice explains why Musters Medical Practice collects information about you and how that information may be used.

Health care professionals who provide you with care maintain records about your health and any treatment or care you have received previously (e.g. at NHS Hospitals, GP Surgeries, Walk-in Centres, etc.). These records are held and used to help to provide you with the best possible healthcare.

NHS health care records may be electronic, on paper or a mixture of both, and we use a combination of working practices and technology to ensure that your information is kept confidential and secure. Records this GP Practice hold about you may include the following information;

• Details about you, such as your name, address, any carers you have, your next of kin, legal representatives and emergency contact details • Any contact the surgery has had with you, such as appointments, home visits, emergency appointments, etc. • Notes and reports about your health • Details about your treatment and care • Results of investigations such as laboratory tests, x-rays, etc. • Relevant information from other health professionals, relatives or those who care for you

To ensure you receive the best possible care, your records are used to facilitate the care you receive. Information held about you may be used to help protect the health of the public and to help us manage the NHS. Information may be used within the GP practice for clinical audit to monitor the quality of the service we provide.

Some of this information will be held centrally and used for statistical purposes. Where we do this, we take strict measures to ensure that individual patients cannot be identified. Sometimes your information may be requested to be used for research purposes – the surgery will always gain your consent before releasing any information for this purpose.

Risk Stratification

Risk stratification data tools are increasingly being used in the NHS to help determine a person’s risk of suffering a particular condition, preventing an unplanned or (re)admission and identifying a need for preventive intervention. Information about you is collected from a number of sources including NHS Trusts and from this GP Practice. A risk score is then arrived at through an analysis of your de-identified information using software and is only provided back to your GP as data controller in an identifiable form. Risk stratification enables your GP to focus on preventing ill health and not just the treatment of sickness. If necessary your GP may be able to offer you additional services. Please note that you have the right to opt out of your data being used in this way.

Med Management

The Practice may conduct Medicines Management Reviews of medications prescribed to its patients. This service performs a review of prescribed medications to ensure patients receive the most appropriate, up to date and cost effective treatments. This service is provided to practices locally through Rushcliffe Clinical Commissioning Group.

How do we maintain the confidentiality of your records?

We are committed to protecting your privacy and will only use information collected lawfully in accordance with:

• Data Protection Act 1998 and General Data Protection Regulation (GDPR) 2016
• Human Rights Act 1998
• Common Law Duty of Confidentiality
• Health and Social Care Act 2012
• NHS Codes of Confidentiality, Information Security and Records Management
• Information: To Share or Not to Share Review

Every member of staff who works for an NHS organisation has a legal obligation to keep information about you confidential.

We will only ever use or pass on information about you if others involved in your care have a genuine need for it. We will not disclose your information to any third party without your permission unless there are exceptional circumstances (i.e. life or death situations), where the law requires information to be passed on and / or in accordance with the new information sharing principle following Dame Fiona Caldicott’s information sharing review (Information to share or not to share) where “The duty to share information can be as important as the duty to protect patient confidentiality.” This means that health and social care professionals should have the confidence to share information in the best interests of their patients within the framework set out by the Caldicott principles. They should be supported by the policies of their employers, regulators and professional bodies.

Who are our partner organisations? We may also have to share your information, subject to strict agreements on how it will be used, with the following organisations;

• NHS Trusts / Foundation Trusts • GP’s • NHS Commissioning Support Units • Independent Contractors such as dentists, opticians, pharmacists • Private Sector Providers • Voluntary Sector Providers • Ambulance Trusts • Clinical Commissioning Groups • Social Care Services • Health and Social Care Information Centre (HSCIC) • Local Authorities • Education Services • Fire and Rescue Services • Police & Judicial Services • Voluntary Sector Providers • Private Sector Providers • Other ‘data processors’ which you will be informed of

You will be informed who your data will be shared with and in some cases asked for explicit consent for this happen when this is required.

We may also use external companies to process personal information, such as for archiving purposes. These companies are bound by contractual agreements to ensure information is kept confidential and secure.

Access to personal information

You have a right under the Data Protection Act 1998 to request access to view or to obtain copies of what information the surgery holds about you and to have it amended should it be inaccurate. In order to request this, you need to do the following:

• Your request must be made in writing to the Practice Manager – for information from the hospital you should write direct to them • There may be a charge to have a printed copy of the information held about you • We are required to respond to you within 40 days • You will need to give adequate information (for example full name, address, date of birth, NHS number and details of your request) so that your identity can be verified and your records located

Objections / Complaints

Should you have any concerns about how your information is managed at Musters Medical Practice, please contact the Practice Manager. If you are still unhappy following a review by the practice, you can then complain to the Information Commissioners Office (ICO) via their website (www.ico.gov.uk).

If you are happy for your data to be extracted and used for the purposes described in this privacy notice then you do not need to do anything. If you have any concerns about how your data is shared then please contact the Practice Manager.

Change of Details

It is important that you tell the person treating you if any of your details such as your name, address or telephone number have changed or if any of your details such as date of birth is incorrect in order for this to be amended. You have a responsibility to inform us of any changes so our records are kept accurate and up to date.

Notification

The Data Protection Act 1998 requires organisations to register a notification with the Information Commissioner to describe the purposes for which they process personal and sensitive information.

This information is publicly available on the Information Commissioners Office website www.ico.org.uk

Musters Medical Practice is registered with the Information Commissioners Office (ICO).

Who is the Data Controller?

The Data Controller, responsible for keeping your information secure and confidential at Musters Medical Practice is:

Dr Laura Turnbull

Complaints

Should you have any concerns about how your information is managed by the Practice please contact the Practice Manager at the following address:

Musters Medical Practice

50-60 Wilford Lane

West Bridgford

Nottingham

NG2 7SD

For more information about the Data Protection Regulations visit:

https://ico.org.uk/for-organisations/guide-to-data-protection/guide-to-the-general-data-protection-regulation-gdpr/

• • You will be treated with courtesy and respect by all Practice personnel.

• • An urgent appointment with a Doctor or Nurse Practitioner will be available on the same day.

• • A non-urgent appointment with a doctor will be offered within 72 hours

• • Our standard is to see 80% of patients within 20 minutes of their appointment time. If you have waited longer than this please ask the Receptionist for an explanation.

• • We aim to answer the telephone within thirty seconds.

• • An appointment with a Practice Nurse will be available within three working days.

• • Requests for repeat prescriptions will be dealt with within 48 hours. This can be in person, by post, by FAX (0115 9813117), via the internet or by the local Pharmacists.

• • All comments and suggestions about the service are welcome. Please use the box provided in the waiting area, via the Patient Participation Group or via the internet:   (www.mustersmedicalpractice.co.uk)

• • If you have a complaint please speak to any member of staff. Your complaint will be dealt with in a professional and efficient manner.

• • We wish to make the as accessible as possible. If you have hearing, visual or physical difficulties please let the receptionist know so that we can enable you to fully use our services.

Patient’s Responsibilities

• • If you are unable to attend for an appointment please let us know so that we can offer it to someone else.

• • If you are late for your appointment you may be asked to rebook at another time. Try to let us know in advance if you are going to be unavoidably delayed, so that we can make alternative arrangements to help you.

• • A home visit should only be requested for those who are unable to come to the surgery because of serious illness or infirmity. Please ring the surgery before 10.00am if at all possible.

• • An urgent appointment is for an urgent medical problem. Please speak to the Receptionist if you require a sick note or repeat prescription.

• • We would ask you to be patient if the Doctor is running late. This is often due to unforeseeable emergencies but please ask for an explanation from the Receptionist.

• • Make a separate appointment for each patient that needs to be seen. This allows the Doctor enough time to treat each patient with the time that they deserve.

• • Please act in a responsible and courteous manner whilst on the Practice premises for the safety and comfort of others.

• • Please treat all surgery staff, fellow patients, carers and visitors politely and with respect. Violence or verbal harassment will not be tolerated or accepted, you may be asked to register at another surgery if this behaviour occurs.

There is a new Central NHS Computer System called the Summary Care Record (SCR). It is an electronic record which contains information about the medicines you take, allergies you suffer from and any bad reactions to medicines you have had.

Why do I need a Summary Care Record?

Storing information in one place makes it easier for healthcare staff to treat you in an emergency, or when your GP practice is closed.

This information could make a difference to how a doctor decides to care for you, for example which medicines they choose to prescribe for you.

Who can see it?

Only healthcare staff involved in your care can see your Summary Care Record.

How do I know if I have one?

Over half of the population of England now have a Summary Care Record. You can find out whether Summary Care Records have come to your area by looking at our interactive map or by asking your GP

Do I have to have one?

No, it is not compulsory. If you choose to opt out of the scheme, then you will need to complete a form and bring it along to the surgery. You can use the form at the foot of this page.

More Information

For further information visit the NHS Care records website

Download the opt out form

Zero Tolerance

The NHS e has a zero tolerance policy of all violence and aggression. This policy is for the protection of all NHS staff, but also for the protection of other patients, their families, visitors, etc. In order to ensure that this zero tolerance approach is adhered to, it is essential to have robust policies and procedures in place. In General Practice, this will need to cover a variety of situations in which incidents could occur. Generally speaking the majority of patients behave in acceptable or manageable ways, however the incidence of excessively aggressive or violent attacks in the GP practice is increasing.

The practice recognises that there can be contributory reasons for patients behaving in difficult or challenging ways, however, where this tips over into aggression or violence, the practice will adopt a zero tolerance approach.

 The Musters Medical Practice aims to provide high quality healthcare and we will treat all patients with respect and dignity. In return we expect all our staff to be treated with respect. We will not tolerate abusive language or threatening behaviour against any member of staff. Such behaviour may result in the offender being denied access to the doctor and/or further measures as appropriate.

Click the link below to view our Dealing with Violent and Aggressive Patients Policy:

http://Zero Tolerance – Dealing with Unreasonable, Violent and Abusive Patient Policy