Croft Hall 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 have rated the practice as Requires improvement for providing safe services because:

Improvements were needed in reporting and investigating incidents and significant events. Learning from the investigations was not effectively shared with staff and systems and processes were not consistently reviewed and developed to improve services.

Systems and processes to monitor peoples prescribed medicines which required additional monitoring did not ensure that people were protected from potential harm.

Documents were not managed to ensure that information in people’s records was accurate and up to date.

Improvements were needed to ensure that the environment and premises were safe to use and adequately maintained; and that infection risks were mitigated as far as possible.

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 service did not always have a proactive and positive culture of safety based on openness and honesty. Concerns about safety were not always fully investigated and reporting of safety events was inconsistent. Processes for identifying improvements did not ensure that learning from safety events was embedded and used to continually improve service delivery. Not all risks had been identified or assessed, and action plans did not always detail fully investigations undertaken and how risk would be mitigated. We were provided with a summary of significant events identified by the practice. There were a total of 5 such incidents on the log. During the course of the assessment and site visit we identified further significant events which had not been documented. In particular, 6 occasions when the police were called and 4 occasions when oxygen was used in an emergency within the practice.

Further information on significant events was requested after the site visit, when this was received it did not correlate fully with the information previously provided. There was a significant event made in July 24, regarding staff safety and security which was not on the original information supplied. This incident had resulted in an action plan being put in place by the provider, but there were no updates to show what actions had been taken.

Complaint records did not consistently show who had responsibility of investigating a complaint; and who was responsible for ensuring actions needed in response to a complaint were taken and monitored. Complaint responses did not include information in relation to duty of candour where needed. (Duty of candour is a legal and ethical requirement for providers to be open and transparent with people receiving care which includes offering an apology when things go wrong.)

The service was not able to provide evidence of meeting minutes that took place to demonstrate that areas of risk were discussed to share learning from events and incidents.

There was a process for managing documents and staff told us they were usually able action these within a reasonable timeframe. Information on urgent referrals requested showed that prior to this assessment there had been 112 such referrals in the past 3 months and all were actioned within 1 day. However, we did not receive any supporting evidence to confirm this. There was no information provided to people advising them what to do if they did not receive an appointment within the expected timeframe.

Information from our clinical searches showed that coding of records (a system to identify relevant medical conditions and monitoring needs applied to patient records, to enable searches to be carried out to ensure actions were being taken) was not consistently completed or was absent in some cases. For example, 3 of the 5 records we looked at for people on disease modifying medicines did not have a code on their records indicating they were on these medicines. We requested information on how the provider assured themselves that staff were consistently coding information. Their summarising protocol gave examples of recommended codes, but did not specify which ones were to be use in practice.

One complaint received by the practice related to a delay in childhood immunisations, due to a baby not being registered promptly. When we reviewed tasks within clinical records we saw there were 12 babies with outstanding registration requirements..

We looked at the oldest task awaiting action dated 17 March 2025, this related to a discharge summary from secondary care from January 2025. Actions included repeating blood tests and reviewing pain medicines, this had not been started.

The service did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They did not always share concerns quickly and appropriately.

Staff employed by the service were trained to the appropriate safeguarding levels for their roles, which included the Mental Capacity Act 2005. There was a lack of evidence for locum staff and their level of training in safeguarding. There were no systems in place to show how the provider assured themselves that locum staff had the appropriate skills and competencies to provide care and treatment for people and mitigate risk of harm.

An alert was placed on people’s records to indicate they were subject to safeguarding concerns. There was no evidence of investigations into safeguarding concerns or learning being shared from incidents.

The provider worked with people to understand and manage risks enabling them to make informed decisions. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Staff understood the procedure for acting on safety alerts and the checks they would make to ensure action was taken, we saw this was followed. We did not receive direct feedback on people’s involvement in managing their care and treatment.

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

The practice had a fire action plan which stated periodic fire drills should be carried out to ensure employees are familiar with the procedure at least twice yearly and records kept. On the day of the inspection, we were unable to find these records, but we were advised a fire drill had been carried out on 19 March 2025.

The practice did not do all that was reasonably practicable to mitigate risks to the health and safety of people who used the service and staff. For example, we were unable to view records that the fire alarm and detection system was subject to regular maintenance and weekly testing in line with best practice.

During a walk around the building, we saw fire doors being kept open with door wedges rather than the approved fire door closers. We were advised that the correct closers would be ordered following the inspection.

The practice had an external fire risk assessment dated 7 March 2022; however this had not been updated since the new provider took over in August 2023, and it was not clear if there were any regular updates in place. The fire risk assessment also stated that there was an extreme lack of action to complete the significant findings from the previous fire risk assessment dated January 2020, which stated there were no arrangements for the means of escape for people with mobility needs. The risk assessment advised the use of evacuation chairs and for nominated staff to be trained to use the equipment. On the day of inspection there were no evacuation chairs in the property, however the practice ordered these following our site visit. The service provided users with access to the premises with ramps and rails for wheelchair access and lifts to gain access to higher levels, although there was no light to one of these lifts they were functional during our visit. However, the lack of a fire evacuation chair to the upper levels made using the lifts a risk to the service user.

Not all equipment within the practice had been checked and calibrated as required, for example, we found a defibrillator had not been checked since May 2023. After the site visit the provider provided information indicating that calibration of equipment would be carried out in April 2025.

Improvements were needed to manage risks associated with the premises, to ensure people were safe and there was a safe working environment for staff. The practice did not have an overarching risk register to identify and manage risk. For example, there was a lack of oversight of maintenance and updating of the premises to ensure it was safe for people who used the service and staff. There had been a number of incidents where the police had been called out due to alcohol and drug paraphernalia being left within the car park and garden area making this unsafe, as well as staff reporting abuse by individuals who were found sleeping within the grounds. The provider said there were plans for secure fencing to be installed but was unable to provide a timescale for this work to be completed. The provider had also failed to notify CQC of these events as per CQC requirements.

Recruitment and training processes did not ensure that all staff were suitably experienced, competent, and able to carry out their roles.

We reviewed 5 staff files, 3 clinical and 2 non-clinical and found 2 of these files were missing some of the required information under Schedule 3 of the Health and Social Care Act 2008.

We were unable to find training records for a member of staff working as a wellbeing co-ordinator, and an administrator member of staff.

The provider could not evidence that locum staff had completed training identified as required within their policy.

Improvements were needed to promote continuity of care for people who used the service. There had been a notable staff turnover: 2 salaried GPs and 2 Practice Nurses had left the practice at the end of November 2024. None of these roles had been recruited into and all clinical care was provided by locum staff at the time of the site visit. There were 2 regular locum GPs, who during the period 3 March 2025 to 20 March 2025 had worked a total of 12 sessions out of the 54 scheduled. On the 12 and 13 March 2025 there were no GPs scheduled to work at the practice.

Locum practice nurses were not offered supervision sessions and the provider did not have a system to monitor the work these clinicians carried out, to ensure they were working within the scope of their competencies.

Staff appraisals were not carried out regularly for all staff, we found some staff had not had an annual appraisal in line with practice policy.

The provider was unable to ensure that staff were appropriately supported; or learning was put into place and monitored., Clinical, non-clinical and safeguarding meetings had not occurred since May 2024. Staff reported that daily huddles took place however, these were not recorded to show what had been discussed.

The provider’s training matrix did not evidence that staff had received appropriate training on supporting people with autism or learning disabilities. As part of the Health and Care Act 2022 all health and social care providers are required to provide training for their staff in learning disability and autism, including how to interact appropriately with autistic people and people who have a learning disability. This is to address persistent and significant health disparities that autistic people and people with learning disabilities face.

We found people were not fully protected from the risk of infection because premises and equipment was not always clean and hygienic. Clinical areas were visibly dusty, with one room having mould around the window, bins were found in the reception areas that did not have lids and were not pedal operated to minimise the spread of infection. Radiators within communal areas were not covered and did not have signs that they were hot to touch, therefore there was a risk of scalding.

The practice had an infection prevention and control (IPC) policy however this was not up to date as the named lead for IPC had resigned from the practice and had not been replaced.

There was a risk that infection control risks had not been identified and subsequently mitigated, which placed people at risk of harm. An IPC risk assessment had been completed in July 2022 but had not been carried out since in line with best practice. Additionally, we were not provided with any evidence of in-house completed IPC audits.

Personal protective equipment (PPE) was not available in all the clinical rooms we inspected for example; one clinical room was missing couch liners and another room did not have any gloves available to use .

The provider could not demonstrate how they ensured that cleaning was undertaken within the practice. We were advised that an external company was used for both daily and deep cleaning however the records we saw to evidence that cleaning had taken place were not up to date. The last date these had been completed was in October 2024. There were no monitoring processes to ensure that cleaning was carried out and the risk of infection was minimised.

Sharps boxes were not securely stored to make sure that they could not be knocked over, in addition they had not been dated when opened.

We reviewed all patient group directives (PGDs) used in the practice and found 5 had been signed after they were authorised. This meant that staff were not appropriately authorised to administer these medicines safely. There was no information on whether the practice had assessed the competencies of staff designated to authorise PGDs. We found duplicates of 4 PGDs in use at the practice. (PGDs allow specified health professionals to supply and/or administer medicine without a prescription or an instruction from a prescriber).

The prescribing protocol referred to a clinical commissioning group outside of Devon where the practice is situated. This did not ensure that clinicians were directed to refer to the relevant formulary for the area.

Improvements were needed in making sure that all relevant monitoring, tests and reviews were carried out to ensure that medicines were prescribed safely. There were shortfalls in promoting optimal care for people who used the service. Results from clinical searches undertaken on 13 March 2025 showed: there were shortfalls in monitoring high risk medicines, medication reviews had limited details of what was discussed, and there were errors in coding which indicated that a full medication review had been undertaken when this was not the case. For example, 2 of the 5 people on lithium (a medicine used to treat mood disorders such as mania) whose records we looked at did not have recent blood test result documented, to ensure it was still safe to prescribe. The practice provided us with information after the clinical searches which showed that people had been contacted to attend for review. We also found that people on multiple medicines had not had a review undertaken in line with guidance.

Prescription stationery was not managed safely in the practice. Prescription stationery was stored in an unlocked printer, in a clinical room which was not locked. These were removed at the time of the site visit.

Prescription stationery logs provided by the practice did not fully demonstrate that they were monitored effectively. There was no clear audit trail of what prescriptions had been used.

We looked at the storage of vaccines within the practice and found that fridge temperature checks had only been completed in the morning for the months of October, November December 2024 and January and February 2025. None had been completed in March 2025, the policy stated that checks should be carried out daily.

The practice had appropriate medicines to use in an emergency and we saw these were routinely checked to make sure they were safe to use. On the day of the site visit we found that the oxygen cylinder levels were in the red zone of the measuring device and no arrangements had been made to replace it. We were told that the practice had needed to use oxygen on 4 separate occasions for people whose condition had deteriorated and oxygen was required while waiting for an ambulance. These incidents were not captured as significant events. We asked the practice to source more oxygen supplies as a matter of urgency and we were provided with evidence to show that this had been done. A new policy was implemented after the site visit to show how oxygen supplies would be monitored in the practice to ensure that there were adequate supplies.