Nettlebed Surgery

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• 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 found some systems designed to protect patients from the risk of harm were not always monitored and operated within a coherent system of governance. We identified risks related to the management of medicines and preparedness for medical emergencies. There was insufficient oversight of staffing requirements and support for staff. There were systems to ensure safeguarding of vulnerable adults and children. Most risks associated with premises and infection control were managed effectively.

This key question has been rated as requires improvement.

This service scored 53 (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 culture of openness and honesty regarding the reporting of concerns and incidents by staff. However, there was not a system to monitor incidents and identify themes from them or complaints. Incidents and complaints were investigated but not always reflected on and not reviewed in terms of learning outcomes or to ensure completion of actions. The was no log for incidents and complaints in order to track progress of investigations or identify themes from intelligence gathered from reported incidents and complaints.

The service 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. We saw evidence that suggested referrals and test results were managed in a timely way.

The service worked with people and healthcare partners to ensure patient safety and the best way to achieve that based on people’s individual needs. They concentrated on improving people’s lives while protecting their right to live in safety, free from abuse, discrimination and neglect.

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 provider with other organisations.

Staff knew who the safeguarding lead was and felt able to report any concerns to them.

The service worked with people to understand and manage risks by planning care with patients. They provided care to meet people’s needs that was safe, supportive and helped people to do the things that mattered to them where feasible.

Emergency equipment was available but not checked sufficiently to ensure it was ready when needed. We found an Oxygen cylinder was out of servicing date by 12 months. The emergency medicines stored were not appropriately risk assessed to ensure they met national guidance and risks related to the services provided. Atropine and Naloxone were not stored onsite but minor surgery was sometimes provided and opiates were dispensed onsite. The provider informed us they were remedying these risks after we highlighted our findings.

Staff could recognise a deteriorating patient and knew of action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

All staff were trained in basic life support. Reception staff had undertaken sepsis awareness training.

Some risks related to the management of premises were not assessed and mitigated through governance systems. There were contractors in place to maintain the premises and ensure remedial work was highlighted and this was undertaken in most cases. However, we found actions required from a fire risk assessment which took place in September 2025 had not been completed. This included the safe storage of oxygen. The dispensary was not securely managed, with access to controlled drugs not limited to authorised staff.

The premises were well maintained and clinical treatment rooms were equipped appropriately.

There was a business continuity plan in place which was monitored and reviewed.

The service did not make sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. A GP and nurse had left the practice in early 2026 and other clinical staff had left in the previous 2 years. There was a clinical pharmacist on maternity leave at the time of the inspection. The provider had not implemented appropriate cover arrangements in the short term and did not recruit sufficient roles to ensure staffing was at a safe level to maintain quality services for patients. Access to appointments was being maintained through utilising clinical staff administration time for appointments. There was insufficient staff cover for the dispensary. The staff team were highly dedicated and experienced, however there was consistent reporting of intense pressure on finding appropriate clinical resource for tasks and appointments.

Newly employed staff did not complete a full induction. We found one staff member who started their role in early 2026 had been provided with a list of patients to see on their first day working at the practice without an induction or check of their training and competencies to ensure they were safe in carrying out their role. Ongoing staff training was not monitored to ensure staff were competent and skilled in their roles. The training matrix indicated several members of staff did not have training in line with the practice’s own requirements. The provider had not ensured all dispensary staff had appropriate qualifications and training. A member of the nursing team who was an independent prescriber had not received clinical supervision of their prescribing from the provider. Dispensing staff did not receive appropriate professional development for their roles.

Staff background checks were undertaken on staff to ensure they were safe and fit to work with patients. This included Disclosure and Barring Checks (DBS) (background checks to ensure people are not barred from working in certain roles).

The service assessed and managed the risk of infection. They detected and controlled the risk of healthcare related infections, with appropriate agencies where necessary.

We found that infection prevention control (IPC) training was available to staff but was not monitored to ensure their periodic completion. The practice had a designated IPC lead, and they informed us they received appropriate advanced training. The IPC lead did not have the necessary time oversee all tasks due to limited hours onsite, of which some of their administration time was used to provide appointments where there was a shortfall in nursing time. Therefore, some tasks

were missed. For example, the washable privacy curtains had not been washed since 2022 and this had not been identified on the IPC audit.

The service had systems to ensure medicines and treatments were safe and met people’s needs, capacities and preferences. The practice had robust recall processes in place, to ensure patients were prompted when they needed a medicine review. A variety of communication methods were used to engage with patients, including text messaging, letters and telephone calls. The remote clinical searches we undertook on the provider’s record system indicated the majority of patients received the appropriate regular checks needed to ensure safe prescribing. We found some patients did not have full structured medication reviews when required but rather these patients had a basic check listed on their record when required. Some acute prescribing for patients with asthma was not undertaken in line with national guidance. Our clinical results indicated patients were not being followed up to check responses to treatment in an appropriate timescale following acute exacerbation of asthma.

Staff who worked in the dispensary and the nurse prescriber did not receive regular training and did not have their competency in line with national guidance.

The practice had a dispensary and was able to dispense medicines to a proportion of its patients. We looked at the processes and systems to ensure patients received their medicines safely and that medicines were stored safely. We found significant gaps in the governance and risk assessments of the dispensary. We identified numerous concerns. Prescriptions were not signed by the prescribing clinician before being dispensed.

The security and access to the dispensary, including controlled drugs (CDs) was not managed appropriately to limit access to authorised members of staff. The management of NHS prescription stationery was not carried out in line with national guidance, posing a risk that these prescriptions may be used inappropriately. The record keeping of CDs was carried out appropriately. However, during the assessment visit, we found broken ampules of patient-returned CDs. There was insufficient auditing of the CDs and other aspects of dispensing. Medicines refrigerator temperatures were found to be out of range over the past 6 months, with insufficient action or checking to assure the efficacy of the medicines stored in it. The dispensary room temperature was not being monitored to ensure the ambient temperature was suitable for the stocks of medicine.

We found that PGD’s (Patient Group Directions) were completed appropriately to authorise staff to administer vaccinations. These are agreed guidelines for non-prescribing clinical staff to administer certain medicines.

Medicines stored in the nursing team’s vaccine fridges, including vaccinations, were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines. The provider had effective systems to manage and respond to safety alerts and medicine recalls.