Cricklade 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 changed to inadequate.

The service was in breach of legal regulation in relation to safe care and treatment, staffing and fit and proper persons employed.

This service scored 28 (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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

We received feedback from staff who reported they did not feel confident to provide feedback to leaders or that feedback would be acted upon. During our conversations with staff, we heard about incidents that would constitute a significant event. However, on review of the service’s significant event log, none of these incidents had been reported, recorded or investigated.

Learning from events was not consistently completed. For example, a person experiencing chest pain presented at the service when no clinician was on site. The person was directed to attend the local hospital’s emergency department. A significant event was raised, and an action was set to update the service’s chest pain protocol. However, when we reviewed the protocol, it had not been updated to reflect what staff should do if this situation occurred again, nor was it displayed in the reception area for staff to access. This information was shared with the service leaders so they could make the changes they originally planned.

The service did not have an effective system to assess, monitor and improve the quality and safety of the service. For example, whilst significant events and complaints were recorded in paper files, the system was not effective. Complaints and significant events were not easy to monitor and review. Entries were not stored in a consistent order, making it difficult to identify the nature of each record. In some cases, significant events had originated from complaints, but this was not clearly documented or easy to trace within the service’s system which resulted in the leaders being unable to demonstrate their current stages and actions taken.

The service was unable to provide any meeting minutes, or evidence of discussions held with the service team or with other multidisciplinary teams where significant events and associated learning had been reviewed.

The service provided a list of patient participation group (PPG) members but was unable to supply recent meeting minutes. The service was also unable to identify which PPG members could be contacted for feedback and could not demonstrate any service improvements resulting from engagement with this group.

The service did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services.

Test results were not managed in a timely way. For example, there were 232 pathology test results awaiting review, including both normal and abnormal results. The oldest result dated back to 5 September 2025. This backlog presents a risk as delays in reviewing results may lead to missed or delayed treatment, putting people’s health and safety at risk.

Staff told us a nurse also supported with checking incoming test results and would inform a GP of any concerns when required. However, training related to interpreting test results could not be evidenced for this nurse during the inspection.

The service could not provide any evidence of meetings held with other organisations involved in people’s care, nor any records showing discussion of shared learning or coordination between services.

However, the service did monitor delays in referrals and had processes to track cases. For example, audits were conducted to ensure urgent cancer referrals were being appropriately booked with secondary care providers. These are urgent referrals used to investigate symptoms that may indicate cancer.

The service did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not 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 share concerns quickly and appropriately.

Staff were not up to date with expected safeguarding training requirements relevant to their role. During our inspection, we asked staff about safeguarding scenarios and what actions they would take in response. Staff were unable to provide examples of what they would do in safeguarding situations and demonstrated a lack of knowledge about who to contact or how to make appropriate referrals.

The service held a list of vulnerable people; however, the list was not being effectively maintained and there was no designated person to monitor this or a process to follow. The service held a risk register, but this was not being regularly reviewed. The child register was last checked in March 2023, and the adults’ register in April 2023. The service was unable to provide any evidence that regular safeguarding meetings or discussions were taking place for people using the service who may be, or are, at risk.

The service did not ensure all staff had a current Disclosure and Barring Service (DBS) check. We were also informed clinical staff were responsible for chaperoning duties, yet these staff members did not have a DBS or risk assessment in place, as required by the service’s own policy. This means people could be put at risk because staff were not properly checked or assessed to keep them safe.

The service did not always work well with people to understand and manage risks. They did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Emergency equipment was available. However, an audit of the medicines stored showed unclear documentation regarding which items were kept in the emergency bag, and which were stored in the dispensary. This created a risk of delays when responding to an emergency. Medicines kept for emergency use were not stored in line with national guidance, for example, they were not stored in a tamper‑proof manner. This meant the service was unable to demonstrate the safe storage of these medicines or confirm when they were last used. As a result, there was a risk of medicines being misused, lost or unavailable during an emergency, compromising safety.

Reception staff were responsible for triaging appointment requests received by telephone, in person and through e‑consults. However, these staff did not receive additional training or have triage tools to support them in this responsibility. staff could access clinical support as needed, however a clinician was not always available onsite.

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

The service did not ensure the premises used by staff and people met essential health and safety requirements. For example, the service’s health and safety policies were overdue for review. Staff members recorded as the service’s health and safety leads were former employees and were no longer at the service. Therefore, there was no designated person currently responsible for health and safety within the service. This meant there was not an identified person responsible for ensuring the service remained safe.

We requested evidence of an annual health and safety risk assessment, as required by national guidance. However, this was not provided. The service did provide evidence of the emergency lighting being last checked in October 2024. However, emergency lighting should be checked monthly. The service’s most recent Gas Safe certificate was dated 19 August 2024, which is an annual requirement under national legislation. In response to this, the service scheduled a Gas Safe review to be conducted within 5 weeks of our onsite visit.

The[JS1] service was not following national guidance in relation to fire safety. The last fire risk assessment was completed in March 2022, despite annual assessments being required under national fire safety guidance for healthcare premises. The service was unable to provide evidence of fire drills taking place or that weekly fire alarm testing was being carried out. Staff told us the neighbouring library, who share the building with the service, conducted these weekly, but there was no evidence of this shared responsibility or any recording system in place. There were no appropriately trained fire marshals at the service at the time of our inspection, which meant people using the service and staff were at risk of potential delays or unsafe evacuation. However, we did not identify any fire safety issues during our onsite visit to the service.

The service did not have adequate security measures in place to restrict access to the dispensary. All staff employed by the service were aware of the key safe code used to access the dispensary keys. This meant there was no control over who could enter the dispensary, which created a significant risk to unauthorised access to medicines, potential misuse and theft and lack of accountability for medicine handling.

The service did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

There was no effective system or process in place to ensure recruitment complied with Schedule 3 of the Health and Social Care Act 2008. During our onsite visit, we reviewed 6 staff files, none of which contained the required information to confirm the suitability of persons employed for regulated activities. There was no evidence appropriate inductions, supervision or appraisals were taking place to ensure staff could carry out their duties safely and effectively.

The service did not have an effective system to ensure clinical staff were compliant with recommended immunisations. As a result, the service was unable to demonstrate staff were adequately protected against vaccine‑preventable diseases, creating a risk to both staff and people. Not all staff had up‑to‑date immunisation records on file, and there was no immunisation policy in place.

The service also lacked an effective system to maintain oversight of staff training completion. For example, the training policy did not specify which modules were mandatory for staff. Although it stated new starters required training assessments, the service could not provide evidence to show these had taken place. Role‑specific training was also not being monitored, increasing the risk that staff may not have the necessary skills and knowledge to carry out duties safely. As a result, on review of the service’s training matrix, we noted all 10 staff members employed at the time of inspection, did not have up‑to‑date training. For example, 9 out of the 10 staff did not have current basic life support training.

The service failed to make sure the lead nurse, who was responsible for supervising and appraising other staff members, had received supervision, appraisals, or clinical oversight themselves. There was no evidence to show competency checks had been carried out for this role.

The service did not ensure sufficient numbers of appropriately trained staff were deployed. Staff told us there were occasions when no clinicians were present on site. Leaders stated in such circumstances, staff would rely on their basic life support training. However, our review of the training matrix showed this training was not completed or up to date for all staff. This meant the service did not have adequate staffing arrangements to ensure people would receive safe care in the event of a clinical emergency, and staff were not equipped with the required skills or current training to respond appropriately.

The service did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The service did not ensure appropriate Control of Substances Hazardous to Health (COSHH) risk assessments were in place from their external cleaning provider, as required by national guidance. Cleaning products were stored in unlocked cupboards, and there was no evidence of completed cleaning schedules to demonstrate effective and frequent cleaning. Despite these concerns, the service environment was observed to be clean and tidy, and all hand‑wash dispensers were full, with appropriate hand hygiene arrangements in place.

The service did not have an up‑to‑date Infection Prevention and Control (IPC) policy, nor was it reflective of current staffing as it referred to a staff member who was no longer at the service. There was no evidence of hand hygiene audits or audits of aseptic non‑touch technique having been completed at the time of our onsite visit. We fed this back to the IPC lead, who confirmed they planned to introduce these audits in the future but no set date for this action was confirmed.

Staff were unable to readily identify the location of spillage kits. There was no IPC risk assessment in place, the IPC policy was overdue a review and did not reflect national guidance. The policy also did not include isolation procedures for suspected infections.

Clinical waste was correctly tied and disposed of in appropriate bins; however, clinical waste bags were not being labelled, as required by NHS England and Health and Safety Executive (HSE) standards.

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

As part of our assessment, we conducted a series of remote clinical searches and records reviews.

Out of the 4 people who have chronic kidney disease (CKD) stages 4 or 5, 3 people were identified as being overdue with required blood test monitoring. We reviewed these 3 records, and all had readings outside of the recommended range in relation to blood pressure monitoring and 1 person was now due for their blood test monitoring.

Out of 130 people diagnosed with hypothyroidism, 2 people were identified as being overdue for their thyroid function test monitoring. Both did not have evidence that monitoring had been checked prior to issuing their last prescription.

Out of 8 people prescribed Disease‑Modifying Anti‑Rheumatic Drugs (DMARDs), such as Methotrexate, we reviewed 5 records. None of the 5 records had the specific day documented for when the medicine should be taken. This is important because Methotrexate must only be taken once a week, and not recording the specific day increases the risk of people taking it incorrectly. During our clinical searches, an enhanced search had to be run because existing coding did not reliably identify these people. This enhanced search identified the 8 relevant records.

Out of 519 people prescribed ACE inhibitors, which help manage blood pressure and protect kidney and heart function, 14 people were identified as not having received the required monitoring. We reviewed 5 of these records and there was no evidence proactive measures by the service to encourage uptake of blood monitoring despite recent prescriptions being issued.

We also reviewed the service’s compliance with Medicines and Healthcare products Regulatory Agency (MHRA) alerts. The specific alert reviewed related to Topiramate. This medicine is used for migraine and as an anti‑seizure medication and must not be prescribed to women of childbearing age, unless they meet the requirements of a Pregnancy Prevention Programme. We reviewed 3 records, and 2 records contained no evidence a pregnancy prevention plan was in place and all 3 had no annual risk acknowledgement forms completed.

The service was unable to demonstrate a suitably responsible individual had been appointed to receive and disseminate Medicines and Healthcare products Regulatory Agency (MHRA) alerts.

Out of 115 people identified as being prescribed an SGLT‑2 inhibitor a class of medication used to manage type 2 diabetes, we reviewed 5 records. Everyone prescribed this type of medicine should be informed of the associated risks and education in relation to Ketoacidosis and Fournier’s gangrene. All 5 records reviewed did not show evidence of people being informed of these risks. The service did not have a policy in place relating to SGLT‑2 medications.

Our remote clinical search of people with a potential missed diagnosis of chronic kidney disease (CKD) stages 3, 4 or 5, identified 70 people. Of these 70 people identified, 5 records were reviewed. Of those 5 records, 4 contained no information to demonstrate the person had been not informed of this potential diagnosis, and 1 such person was last communicated with regarding this in 2023. All 5 records reviewed did not show evidence of any additional investigations being triggered to confirm a diagnosis. This was not in line with NICE guidelines.

However, out of 233 people with diabetes, 29 people were identified as not having a high HbA1c blood result. We reviewed 5 of the records and all of those 5 records reviewed all people had received their annual review.

During our clinical searches, we also attempted to review medication reviews. Many people had been incorrectly coded as having received a medication review, when in fact they had not. This was due to some staff using the clinical system’s coding function incorrectly.

The service was informed of the findings of the clinical searches during the inspection, and we requested information on how the identified people would be followed up. This information was not provided by the service within the deadline given.

We reviewed the service’s Patient Group Directions (PGDs) and Patient Specific Directions (PSDs). PGDs are written instructions that allow healthcare professionals to supply or administer certain medicines to groups of people without a prescription. PSDs provide written, personalised instructions for an individual, tailored to their specific clinical needs. PGDs were reviewed regularly and kept up to date, helping to ensure people received the correct treatment as planned. However, when reviewing 5 records where a PSD should have been in place, we found 2 people had been administered an injectable medication without a valid PSD recorded. In both cases, a nurse had documented a PSD had been reviewed, when in fact no PSD existed. This represents a significant risk, as medicines were administered without the legally required authorisation.

The dispensary was not operating safely or in line with the service’s own standard operating procedures (SOPs). Staff told us an untrained member of staff had been removing controlled drugs from the premises and transporting them to the service’s branch site at Ashton Keynes Village Hall for medicine delivery. The service took immediate action to stop this and revised the relevant SOP to ensure people prescribed controlled drugs now attend the main site in person to collect their medicines from trained staff.

The service had not ensured staff working alongside the dispensary team had the necessary training or understanding of the dispensary SOPs. For example, some reception staff told us they had been supporting the dispensary by handing out prescribed medicines, despite not having read or been trained to do so. This created a risk that people may not have been receiving their medicines safely.

However, the dispensary team described a clear process for stock rotation, which reduced the risk of medicines becoming out of date. The service also had appropriate arrangements in place for recording, storing and disposing of medicines, including controlled drugs.

Refrigerated medicines and vaccines were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all these medicines and vaccines. We reviewed a sample of medicines and vaccines during our onsite visit and found no evidence of out of date stock.