Castlegate & Derwent Surgery

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

At our previous inspection in 2023, the practice was rated requires improvement at providing a safe service because they were unable to demonstrate that safe systems and processes were in place. At this assessment we have rated the practice as requires improvement. We found; Safeguarding systems, processes and practices were not sufficient. There was no robust system regarding significant events and complaints in which the practice took time to share learning. Recruitment checks were carried out in accordance with regulations. The practice were able to provide up to date health and safety and infection, prevention and control risk assessments. After the assessment the provider informed us of improvements they were making in response to our findings. We will review these at our next assessment.

This service scored 41 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

A new complaints system had been implemented in January 2024. This system followed the practice complaints policy in that complaints were dealt with in a timely manner. However, we noted 78 complaints that had been made prior to January 2024 were yet to be fully processed. We spoke with staff who were unsure as to whether this backlog had been dealt with. They agreed to write to each complainant to ascertain whether their complaints had been dealt with to their satisfaction. Therefore there was limited evidence as to whether patients had been involved in any learning.

The practice told us that as well as a backlog of complaints they also had a backlog of significant events to process and learn from. We did not see evidence of changes in the practice since the last report and the people's experience reflected this. Staff who were in a position to oversee complaints and significant events had not received training to enable them to mange this effectively. Furthermore, the backlog of complaints had been highlighted to the leadership team, at the time of site visit no strategy had been implemented to manage this. When we spoke with staff they told us that learning from complaints and significant events was not always shared efficiently across the whole practice team. The leadership team told us they communicated via email, newsletter and had held meetings but not with all of the staff present. They acknowledged that the practice was experiencing operational difficulties and at times, they struggled to complete all the necessary tasks around learning.

We saw no evidence that demonstrated staff felt included as part of the significant events processes. Furthermore we saw no evidence that staff were advised of learning derived from significant events. We reviewed evidence from staff who told us they did not feel included or part of a team, staff described a divide between leadership and themselves.

Patients told us they received timely referrals. We spoke with care home staff and asked them if the new service was satisfactory. they told us that they struggled to access GP's on behalf of their residents. they had not been consulted on the process and had not been asked for their ongoing feedback.

The practice work in conjunction with other services. The practice told us they had changed the way they supported care home residents. A regular meeting took place at the practice where individual residents were discussed with other professionals such as paramedics and district nurses. a decision was then taken about what support people required and who would provide it. A care-coordinator role had been developed to oversee this process.

We consulted with stakeholders. They continued to express concerns over the practice and how it was run and operated.

Our clinical searches showed very small percentages of patients who had been incorrectly coded or not received the appropriate treatment, the practice resolved these issues when they were highlighted. We noted the practice had not carried out any quality audits to establish whether the new process was successful.

We received no information from patients which indicated the practice had failed to safeguard vulnerable and at risk patients effectively.

Staff who completed the staff feedback questionnaire had a knowledge of who the safeguarding lead was. Staff commented on feeling excluded from meetings. We did not see evidence that safeguarding was being discussed on a regular basis. Our searches showed gaps in safeguarding registers, the practice have provided evidence that since our assessment this how now been resolved.

We consulted with stakeholders. They continued to express concerns over the practice and how it was run and operated.

We saw evidence in staff training which highlighted not all members of staff were trained to level 3 where required. We reviewed evidence during our assessment which showed a lack of regular documented safeguarding minutes. We reviewed evidence which demonstrated a lack of consistent safeguarding updates being provided to a wider team.

At our last inspection the GP National Survey indicated the practice was above average. However, the latest national GP survey carried out in 2024 showed a decline in patient satisfaction both against local and national averages.

We saw meeting minutes involving other healthcare professionals including palliative care, paramedics, health visitors and social prescribers. This demonstrated the practice were working with other disciplines to meet patients needs.

Our clinical searched showed that patients were being appropriately monitored where required. There was a very small percentage of patients who had not received this, however the practice were able to evidence that these patients were difficult to contact.

The patients that we spoke to did not comment on the environment.

Fire risk assessment and Health and Safety risk assessments had been carried out and appropriate actions were taken. Equipment and facilities were clean and tidy. The practice did not store emergency medicines appropriately. Risk assessments were not in place to determine the range of medicines held. The emergency trolley was overflowing, the tamper proof seal was inadequate, and items were not easily accessible or easy to locate. There was no measures in place for monitoring the Doctors bag.

We reviewed evidence which indicated not all processes were being managed effectively. We found that important checks of the emergency trolley were not being carried out properly and doctors bags were not subject to thorough scrutiny.

At our last inspection the GP National Survey indicated the practice was above average. However, the latest national GP survey carried out in 2024 showed a decline in patient satisfaction both against local and national averages. The patients we spoke with also raised no issues with staffing.

Recruitment checks were carried out in accordance with regulations. We found some gaps relating to staff vaccinations. The lead infection prevention control (IPC) nurse was in the process of obtaining staff vaccination and immunisation status'. We spoke with the leadership in the practice. They told us 23 staff had left since our last inspection and recruitment to fill these positions was ongoing. This included recruiting nursing staff, GP assistants and administrative staff. At the time of our site visit, there was no practice manager in post. They were about to implement a system of total triage, total triage means that every patient contacting a practice first provides some information on the reasons for contact and is triaged before making an appointment. They sent us a plan for this which clearly outlined their rationale for change. However, though they had an implementation plan for this there was no clear start date. Staff told us there was not sufficient staff at the practice.

We checked staff records which indicated the practice carried out the required employment checks and there was an induction process. However, a gap was noted relating to a member of staff who did not have the full employment record on file (staff had moved to the practice from the pharmacy). We informed the practice who rectified this.

We saw no evidence which indicated patients had a negative experience of IPC. Patient toilets were clean. Patients had access to water to drink, hand washing facilities and a toilet on all floors.

Staff had received training on infection prevention and control.

The Provider maintained a clean and appropriate environment in managed premises that facilitated the prevention and control of infections. Appropriate standards of cleanliness and hygiene were met. Staff had received effective training on infection prevention control (IPC). Audits were carried out on IPC which identified out of date face masks and alcohol hand gel. The practice acted on the issue identified and placed an order to replenish the stock. Clinical rooms had adequate provisions of personal protective equipment (PPE). Staff managed disposal of waste safely.

We saw evidence that the practice regularly carried out infection control audits. There was evidence that equipment was being checked when required. There was evidence of staff being up to date with required Infection Control training. There was also evidence of the Infection Control Lead attending external training within the last 12 months.

Following our last inspection we received a number of contacts from patients stating they could not collect their medicines from a pharmacy of their choice in a timely manner. this was reflected in the complaints log at the practice and had recently been raised to the local MP via their constituents. The practice had a prescription team who supported patients to order their medicines. The practice patient participation group (PPG) had worked with the prescription team to look at processes to improve access to prescriptions. At the last inspection we discussed EPS AND RPS with the leadership team, following patient feedback. At this inspection this service was still not available to patients, patients continue to consistently express concerns. During the site visit and discussion with practice leadership we were advised that the practice were implementing EPS and RPS, we requested a timeline and strategy but were not provided with one, however following our assessment the practice have implemented EPS.

We spoke with the leadership team about access to medicines and discussed patient concerns with them. They told us they had recently implemented a new system where dedicated staff dealt with repeat prescriptions. However, they acknowledged that there were still issues and as part of their total triage the were implementing EPS. We saw no evidence as to why, as per our previous report, EPS had not been implemented sooner. for example there were no impact statements explaining why the systems implemented in the meantime were of any benefit to the patients. there were no explanations as to why patient complaints did not appear to have been listened to in terms of learning lessons and improving and involving patients.

The practice did not hold appropriate emergency medicines, risk assessments were not in place to determine the range of medicines held. There were no measures in place for monitoring the Doctors bag. There was medical oxygen and a defibrillator on site and systems to ensure these were regularly checked and fit for use. Vaccines were appropriately stored. The fridges were used only to store vaccines and were large enough to allow sufficient space around the vaccine packages for air to circulate. We found some vaccines to be out of date and the recording of the fridge temperatures were neglected on a few occasions. The fridges had one thermometer and staff informed us that data loggers (to support 24 hour monitoring) had been requested.

The practice employed a pharmacist remotely to review letters which required changes to people’s medicines. We saw there were some delays in these letters being actioned. On the day of inspection, the lead GP described how this process was under review to ensure changes were completed in a timely manner. We looked at how the practice was monitoring compliance with the pharmacy Service Level Agreement. We found there was no formal contract monitoring in place. Dispensing doctors’ patients were dispensed medicines by the affiliated GPhC (General Pharmaceutical Council) registered pharmacy under an SLA (Service level agreement). Inspection reports for the GPhC registered pharmacy are available on the GPhC website. There was a process in place to comply with the required Dispensary Services Quality Scheme audits which were submitted annually. A new process had been developed to help the prescribing team support people in receiving medicines reviews in a timely manner. The team described how this was improving oversight of people’s medicines and improving patients’ engagement with medicines reviews.

The service had systems for appropriate and safe handling of medicines however there were areas which required further work.