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 Inadequate. At this assessment, the rating remains the same.

This service scored 25 (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 still did not have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and still did not investigate or report safety events. Lessons continued not to be learnt to identify and embed good practice.

Learning from events still had not been consistently identified, documented or acted on. Learning was not consistently communicated and embedded in practice. As a result, opportunities to reduce the risk of similar incidents occurring were missed. For example, a dispensing error had occurred in the dispensary, but this had not been shared with staff. The following day, in the same error was repeated.

Actions taken in response to complaints were still not always recorded to demonstrate learning or improvements. We reviewed 2 complaints and noted whilst these were managed in line with the service’s policy, actions taken were not always recorded. Staff were able to describe actions that had been implemented but these had not been documented. In addition, 1 complaint we reviewed had not been considered or recorded as a significant event as part of the complaints review process.

We reviewed a complaint where a person was given a bowel disease screening test containing identifiable information about other people using the service, including the reason for their testing. In response to the complaint, the service told us they revised its process to ensure people were given screening tests during their appointments. However, the service was unable to evidence the updated process or the learning identified had been communicated to staff and embedded in practice. The service had also not considered this incident as a significant event and Duty of Candour had not been followed to inform those involved.

Staff told us that learning from events or feedback was not routinely shared with them. Meeting minutes we reviewed from March 2026 also did not evidence discussions of learning or that lessons learned were shared with staff.

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

The service still did not ensure that test results were reviewed without delay. During our onsite visit we identified 9 test results assigned to a staff member who was absent from work, 5 of which were identified as abnormal. The service had not identified this as a risk or ensured the results would be monitored and reviewed to prevent delays in care and treatment. They only became aware of these results after we raised this with them and encouraged them to ensure they were reviewed.

External meeting minutes reviewed from quarterly palliative care multidisciplinary team (MDT) meetings held at the service did not record attendance, meaning it was not possible to determine who was present for key discussions. Staff told us that, although these meetings were held at the service, a clinician from the service did not always attend. This limited the service's involvement and oversight of discussions relating to people's care.

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 still not always clear about the internal escalation process for safeguarding concerns. Staff were also unable to consistently describe how to make safeguarding referrals or identify the appropriate external agencies to contact. Staff told us they would raise concerns with their line manager and would rely on them to escalate concerns to the safeguarding lead and make any necessary referrals. However, we saw that staff were now up to date with safeguarding training relevant to their roles and were able to identify the safeguarding leads in the service.

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

Arrangements for responding to medical emergencies were not effective. The service had still not fully assessed or mitigated risks associated with emergency medicines, including the risk that some medicines may not be accessible when required. During our onsite visit, arrangements did not provide assurance that all emergency medicines would be immediately accessible should a medical emergency occur. In addition, the service was unable to demonstrate effective oversight of emergency medicines stored between the emergency trolley and dispensary, including which medicines were held in each location. Documentation identifying the location of emergency equipment and medicines remained unclear, creating a risk of delays in an emergency response. Medicines held for emergency use were not stored in line with national guidance, as they were not kept in a tamper-proof manner. As a result, the service was unable to demonstrate the safe management of these medicines, provide evidence of when they had last been used, or ensure they were protected from loss, misuse or unauthorised access.

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

Arrangements for health and safety including fire safety, were not effective. Actions identified through risk assessments had not been completed, and the service was unable to evidence compliance dates had been met. Staff were unable to clearly describe the respective roles and responsibilities of the service and the council, as owner of the building, which reduced clarity in the management of health and safety risks. The service was also unable to evidence essential safety checks had been completed, including the electrical wiring certificate and annual fire panel service. Risks identified through the fire risk assessment, as requiring action by the end of March 2026 and May 2026, had not been completed or scheduled. These included servicing of fire safety systems, emergency lighting, fire extinguishers and the gas boiler, as well as repairs to fire safety equipment and completion of a fire door survey.

The service still 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.

During inspection, staff told us they felt staffing levels were low and that some management roles and responsibilities were not always being fulfilled consistently. Staff told us this was because managers were required to cover staff absence by prioritising reception duties and patient access.

The service still had not ensured staff records contained all necessary information to demonstrate that safe recruitment processes were followed. We reviewed 5 staff records and found they were incomplete or information was not always available to demonstrate that appropriate employment checks had been undertaken. Specifically, we found information was missing relating to the interview process, Disclosure and Barring Service (DBS) checks, proof of identity, professional registration checks and information relating to staff members' physical and mental health. Additionally, where health questionnaires identified conditions that could affect a staff member’s ability to carry out their role, no risk assessments had been undertaken to identify appropriate reasonable adjustments. Where information was incomplete or unavailable, the service had not risk assessed the impact of this.

The service had not ensured staff acting as chaperones had received a current Disclosure and Barring Service (DBS) checks. We were told clinical staff were responsible for chaperoning duties, however we found some of these staff members did not have a DBS or risk assessment in place, as required by the service’s own policy. This meant people could be put at risk because staff were not properly checked or assessed to keep them safe.

The service had still not ensured staff responsible for triaging appointment requests received necessary training. Reception staff were responsible for triaging appointment requests received by telephone, in person and through e-consults. However, they had still not received additional training or had access to appropriate triage decision-support tools to help them identify and manage risks. We were told staff could access clinical support as needed; however, on review of staffing rotas, a clinician was not always available onsite during opening hours.

Not all staff who worked alone had completed necessary training to support them in that role. The service told us that to mitigate the risk of lone-working, staff received face to face basic life support training to ensure they could respond appropriately should a medical emergency occur. However, training records showed this had not been completed by all relevant staff. This had not been identified by the service.

The service had not ensured staff received appropriate support and supervision to enable them to carry out their duties. There was no evidence clinical or non-clinical staff received regular supervision. The service had introduced induction documentation; however, records were not consistently completed and did not always demonstrate that all elements of the induction process had been undertaken. This meant the service was unable to provide assurance staff remained competent, supported and up to date with their roles and responsibilities.

However, all staff had now completed training deemed as mandatory by the service. Staff told us they now received protected time during their working days, to complete their online training as a part of their induction programmes.

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 still did not have evidence of cleaning schedules to demonstrate that cleaning was being undertaken effectively and at appropriate frequencies. During our onsite visit, we observed that some cleaning equipment, including wet mops, were being hung up and stored in the COSHH cupboard. We observed moisture damage to the walls and flooring in the cupboard and disposable mop heads were being reused despite being intended for single use. Cleaning products, including bleach sprays, continued to be stored within a kitchen area. This indicated that systems for the safe storage and management of hazardous substances were not being consistently followed. Cleaning records displayed within service toilets, intended to document when areas were checked and cleaned and by whom, had not been completed. The service was therefore unable to demonstrate that routine cleaning and monitoring of these areas was taking place. We raised this with the service who had not identified these concerns. They told us they would raise them with their cleaning provider. Service leaders told us they were in the process of changing to a new external cleaning provider; however, they were unable to demonstrate how they were monitoring or addressing ongoing concerns while waiting for the new contractor to commence in June 2026.

The IPC lead had been newly appointed and had not yet received training for the role. Although the service completed an IPC audit in March 2026 with support from the Integrated Care Board (ICB) IPC Lead Nurse, the audit had not identified all areas of concern including concerns we observed during assessment. At the time of inspection, not all actions identified through the service's IPC improvement work had been completed. Outstanding actions included removing obstructions to hand hygiene facilities, implementing cleaning schedules for infrequently used equipment, and obtaining staff immunisation records relevant to their roles. However, the service had taken steps to address concerns identified on their March 2026 audit. The IPC lead introduced a risk register to record, monitor and progress the IPC actions identified. The IPC lead was continuing to work towards bringing the service in line with recommended IPC guidance. However, we observed during the onsite visit that not all actions required had been identified and recorded on the risk register.

The service had still not ensured clinical waste was stored securely in line with NHS England and the Health and Safety Executive (HSE) standards. For example, the lock on the external door providing access to the clinical waste bins was broken which meant the area was not secure. Additionally, the bins in the storage area were also unlocked. The service had not identified this as a risk. However, clinical waste was now being correctly tied, labelled and disposed of in appropriate clinical waste bins.

However, the service was observed to be clean and tidy. Hand wash dispensers were full, and appropriate hand hygiene arrangements were in place. Hand hygiene audits had been introduced in March 2026.

The service still did not make sure 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 sample of remote clinical searches and records reviews. These included the same searches undertaken during our previous assessment to assess whether improvements had been made, together with additional searches to review other areas of clinical practice.

During our clinical searches and records review, we noted people who used the service were still not always receiving appropriate treatment or follow-up care. We identified continued concerns in the monitoring of care and treatment, medicine reviews, and ensuring people received appropriate advice and support.

The service had not ensured people impacted by Medicines and Healthcare products Regulatory Agency alerts were informed of the risks. For example, out of the 4 people prescribed SGLT2 inhibitors, a medicine used to treat diabetes, heart failure and chronic kidney disease, none had been informed of the associated risks. Whilst the service had taken action to inform people already prescribed this medicine following our last assessment, it had failed to ensure people recently prescribed this medicine were informed of the associated risks.

Out of 37 people who were prescribed ACE inhibitors or Angiotensin II receptor blockers, which help manage blood pressure and protect kidney and heart function, we reviewed 5 records. Of those 5, we identified 1 person who had not received necessary interventions following abnormal pathology results. This exposed the person to the risk of harm which could include symptoms such as muscle weakness and cardiac arrest.

The service had still not ensured people experiencing polypharmacy (defined as being prescribed more than 10 medicines) received a medicine review in line with national guidance. We reviewed 3 out of 155 people identified as experiencing polypharmacy and found that none had received a review in the last 24 months.

The service was informed of the findings of the clinical searches the day they were conducted. We requested information from the service about how the identified people would be followed up. This information was not provided.

However, some improvements had been made. For example, we identified 8 people prescribed methotrexate. Of these, we reviewed 5 records and found that all had received appropriate monitoring.

We also reviewed MHRA safety alerts in relation to topiramate. A total of 3 people were identified, and all 3 records were reviewed. Each record contained the appropriate documentation, including completed forms and risk prevention plans.

The dispensary team now had 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. The service had now updated their standard operating procedure which had been signed by all reception staff, which prevented controlled drugs being transferred to the branch surgery.

Medicines and vaccines requiring refrigeration were stored securely and at appropriate temperatures. Staff regularly checked stock levels and expiry dates, and a sample reviewed during inspection showed no evidence of expired stock.