DeMontfort 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

We looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment, we rated this key question as good. At this assessment, the rating has remained the same. This meant people were safe and protected from avoidable harm. However, some learning events were not always being investigated and documented, there were staffing shortages which lead to backlogs in administration work and the practice not always having assurance that remedial work had been carried out following action plans for building and premises matters.

This service scored 59 (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. They did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

There was a process for investigating incidents and complaints within the practice. It was not always clear that learning from incidents and complaints had been disseminated to the practice team and implemented. Some staff reported incidents which had been raised to management, however it was not clear that actions had been taken to address any risks.
Not all complaints were recorded within the practice as minor complaints were not always reported formally, however it was not clear what was classified as lower level. Some complaints we were made aware of had not been recorded via the reporting system so we could not be assured they had been acted upon. Learning from complaints was not always evidenced to be shared with staff. When formal clinical complaints had been raised, we saw appropriate investigations had been completed and final responses were shared with the complainant. However, acknowledgements were not always recorded to assure that the patient had been contacted on receipt of their complaint.

The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always make sure there was continuity of care, including when people moved between different services.

Due to staff shortages, a backlog of processing patient records for summarising and for returning once they had left the practice had built up. This had been raised with management on multiple occasions without sufficient actions to address it. Following the inspection, the practice put an action plan in place to address this.

There was a process for ensuring referrals were managed in a timely manner within the practice.

At the time of out inspection, there was a backlog in dealing with incoming mail due to staff shortages. We saw that some emails had not been dealt with for three weeks which included safeguarding alerts.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. The practice held a list of vulnerable people who were regularly reviewed by the safeguarding lead from the Willows Group Ltd. Due to the model of the practice, this meant that practice staff did not always have oversight of these patients but could see ongoing reviews within the patient record. The practice utilised icons on the patient records as well as clearly documenting on the patient clinical record if there were safeguarding concerns.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

Emergency equipment was available and maintained. Staff could recognise a deteriorating patient and knew of action to take. The practice had an unmanned waiting area upstairs with limited oversight. We were told that reception staff in an adjoining area would keep an eye on patients for signs of deterioration however due to staffing shortages there was not always staff available within that area.

The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The practice had some oversight of premises and maintenance within the building however when external risk assessments had been carried out and remedial work was required, the practice did not always have assurance that this had been completed in the appropriate timeframe. For example, the fire risk assessment was overdue from April 2025, failed PAT testing items were still on site despite having live wiring exposed and remedial works from the previous fire risk assessment could not be evidenced. Although this was the responsibility of the landlord, the practice did not have oversight that risks within the building were addressed.

The service did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development.

There were a range of clinical and non-clinical roles within the practice. We found training was up to date, learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence. Safe recruitment practices were followed and well organised. However, we found there was a lack of staffing within the administration team however the practice was attempting to recruit more administration staff. We were told that members of staff who had left had not always been replaced, and often administration staff would be taken from DeMontfort Surgery to cover shortages at the other locations managed by the provider at short notice which would again put more pressure on staff. Staff we spoke with had reported increasing workload, and backlogs of work due to this, however staffing levels continued to be low. We were told that clinical staff rotas often changed at short notice to cover other locations owned by the provider, which meant that De Montfort Surgery clinics were regularly cancelled at short notice or had reduced numbers of clinical staff. On the day of our inspection, staff shortages were seen and support staff had not been sourced to support the practice.

There was a process for formal supervision for clinical staff however it was not clear how learning from this was shared to improve care for patients. Some clinicians review highlighted shortfalls in their documentation, however the audits had been marked as good.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. The practice had a designated infection, prevention and control lead and all staff had had relevant training. Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks. On the day of inspection, a small number of consumables were found in clinical rooms that had expired and had not been removed. Leaders immediately removed these items and implemented a system to ensure regular checks were carried out.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

The current provider had taken over the contract for the practice in September 2023 and had worked hard to ensure patients were receiving their medicines safely and adhering to prescribing and monitoring requirements. However some patients were outstanding on monitoring and reviews, which the practice had attempted to contact to arrange however engagement remained low for a small number of patients. The practice had a policy to manage this to encourage uptake of reviews. Due to the practice also having a population of patients who regularly moved areas, there was some difficulty in getting patients to engage when they have moved away from the practice. Work had been done to try and target these patients to see if they were still local however work was ongoing to identify all of the patients who had moved out of the area.

The practice was working hard to find alternative solutions for their population and had implemented some clinical initiatives for specific conditions such as early identification of renal disease however work was ongoing to demonstrate overall impact to patients.

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.

There was regular updates to staff to ensure training was completed and they were updated with any clinical guidance changes. Staff managed prescription stationery appropriately and securely. Medicines including controlled drugs were stored securely and at appropriate temperatures. There were systems in place for staff to check stock levels and expiry dates for all medicines, including emergency medicines, however some stock with short expiry dates had not been picked up during these checks. The practice utilised adrenaline packs which were moved to clinical rooms when required. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments.

The provider had effective systems to receive and share safety alerts and medicine recalls for clinical staff awareness. We saw evidence of some alerts being logged however not all relevant alerts had been recorded as received and it was not clear from evidence logs we saw if actions had been taken. We reviewed the clinical records of some patients who may have been affected by safety alerts, and found the practice had taken time to explain clearly the risks to these patients which was well documented and clear to the patient in a way they understood.

There was a programme of audits which had been completed by the provider which incorporated De Montford Surgery along with their other practices. Although some of these two cycle audits showed improvement, it was not always clear to see the direct impact on patients at De Montford Surgery. Many audits had not yet finished and were awaiting the second cycle to demonstrate improvement.