Castlefields 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.

This was the first assessment for this service since its registration with CQC. This key question has been rated as Good.

This service scored 63 (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 had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. The practice was 1 of 8 practices managed by the provider. To share learning across all practices, the provider sent regular learning bulletins to every location. For example, safeguarding concerns relating to surrogacy and changes in the schedule for childhood immunisations.

People felt supported to raise concerns and felt most staff treated them with compassion and understanding. Managers encouraged staff to raise concerns when things went wrong. Staff we spoke with were aware of why it was important to report significant events.

During clinical meetings, the team discussed and learnt from clinical issues. Staff told us there was an open culture, and that safety was a top priority. The provider had processes for staff to report incidents, near misses and safety events. Staff we spoke with were aware of this process and gave us examples of learning. For example, additional training was provided to administrative staff to ensure blood samples were collected daily.

There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Learning from incidents and complaints resulted in changes that improved care for others. Significant events and complaints were standard agenda items at the monthly clinical meetings. Learning was shared with staff including actions taken and themes identified. An annual meeting was held to review themes in significant events and to evaluate any changes made.
 

The service mostly worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

There were systems in place for processing information relating to new patients. The service worked with other providers to deliver shared care and when patients moved between services. Referrals and test results were managed in a timely way. However, we found 7,172 documents waiting to be filed in patients’ records dating back to 12 March 2026. The provider informed us they had all been reviewed by a clinician. During our onsite assessment, the provider demonstrated the letters had been dealt with however, there was a problem with the IT system in which the letters were first stored. They were working with the IT company to address this. They told us that they were in the process of developing their own IT system which would prevent this from occurring in the future.

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 maintained a list of vulnerable people and acted on concerns working in partnership with other organisations. They also had systems in place for following up children and vulnerable adults who were frequent attenders to AE or failed to attend for hospital appointments. Alerts were added to the records of people with known safeguarding concerns and to the records of people living within the same household.
 

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.

Most of the required emergency equipment was available and maintained. However, we found several items of emergency equipment were not. For example, portable suction and a rebreathe bag and mask for children. The service ordered the required equipment immediately and sent photographic evidence when these had been added to their emergency trolley.

Staff could recognise a deteriorating patient and knew of the actions to take. Guidance on identifying a rapidly deteriorating patient was available for receptionists to refer to and a duty clinician worked in the same room as the receptionists to offer support. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.
 

The service mostly detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Contracts were in place to ensure the premises were maintained. Health and safety risk assessments and audits had been undertaken and risks identified had been addressed and added to the overarching risk log. There was a business continuity plan in place which was monitored and reviewed.

However, we found a small number of patient records were stored in a locked room that domestic staff had access to. The provider moved the records to a locked cupboard to eliminate any potential risks.

The fire risk assessment had identified multiple concerns and rated the practice level of risk as substantial risk to life. We found that an action plan had been put in place and all the identified risks had been acted on. The risks had been added to the practice’s risk register, and the risk had fallen to tolerable. However, on the day of our assessment we found that several fire doors were wedged open. The provider removed all the wedges and safely discarded them. They reminded staff of the importance of not wedging fire doors open. Clinical room doors were not always locked when unoccupied. The provider told us they would raise this with staff.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

There was a range of clinical and non-clinical roles within the practice. We found training was up to date, learning needs and the development of staff were managed appropriately, and staff were working within their agreed areas of competence. Staff received annual appraisals and told us they felt very supported to carry out their roles.

Systems were in place to support new staff working at the practice and competency checks were carried out to confirm they were able to carry out the requirements of the role. A system of auditing the prescribing of non-medical prescribers on a regular basis was in place. Records showed that this was used to inform the monthly clinical supervision sessions for this group of staff.

Safe recruitment practices were followed.
 

The service mostly 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 (IPC) lead and all staff had received relevant training. Cleaning schedules were available for domestic and clinical staff which outlined how staff should clean the building and its equipment. The service demonstrated how these were monitored for completion to maintain oversight of cleaning arrangements. During our onsite assessment, the service's premises and a sample of equipment reviewed was noted to be visibly clean. The service’s IPC lead conducted regular risk assessments and audits to ensure compliance and acted where necessary to mitigate any identified risks. They also conducted regular hand-washing audits.

However, we found that a cleaning schedule for the wheelchair within the practice was not in place; a clinical member of staff was not compliant with the bare below the elbows dress code required in healthcare settings; and a bin for the safe disposal of hand towels and nappies was not available in the baby changing area. Immediately following our assessment, the provider sent us a detailed schedule for cleaning the wheelchair, re-sent staff their safety bulletin promoting the bare below the elbows requirement and informed us a bin had already been ordered.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning.

Staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely. People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms. Staff received regular training, were competency assessed on medicines optimisation, and felt confident managing the storage, administration and recording of medicines.

Medicines were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments.

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. For example, the number of antimicrobials issued by the provider was comparable with national averages. The prescribing of medicines to treat poor mental health was 4%, which was lower than the national average of 6.8%.

There was a programme of regular clinical audits of prescribing that focused on improving care and treatment. Audits had been completed to ensure that the cold chain was maintained when storing medicines and vaccines in a fridge. Changes had been made to mitigate potential breaks in the cold chain in response to the audit.

The provider had systems to manage and respond to safety alerts and medicine recalls. However, they did not always work effectively. We looked at a Medicines and Healthcare products Regulatory Agency (MHRA) alert relating to the unsafe co-prescribing of 2 medicines. We found that 10 patients were on this prescribing regime. We reviewed the records of 5 of these patients and found that none of the patients had been made aware of the risks. During our onsite assessment the provider showed us the action they had taken, and this number had reduced to 1 patient who they were trying to engage with.

Systems to monitor patients who failed to attend for the required blood tests when prescribed medicines that required monitoring were not always effective. In particular, medicines used in the treatment of high blood pressure and medicines used in the prevention of stomach ulcers. Whilst the practice had attempted to recall patients who failed to comply with the required monitoring, a subsequent escalation process was not in place to promote compliance. Immediately following our remote clinical searches, the practice updated their medicine’s policy to reduce the quantity of repeat medicines prescribed and clinical leads for different medicine types were identified. At our on-site assessment, we found that the number of patients that required monitoring had started to fall and learning from the remote searches had been added to their quality improvement programme.

Systems to track prescription stationery throughout the practice were not effective and prescription stationery was not stored securely. Immediately following our assessment, the service updated their medicines policy, locked the cupboard where prescriptions were stored and restricted key access to the cupboard.