Parkwood 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 found that people were not consistently protected from abuse and avoidable harm. At the April 2025 assessment, we identified serious and widespread failures in systems designed to keep people safe. The provider did not have effective arrangements to identify, assess or manage risk, and governance systems were weak. Significant backlogs of unactioned correspondence, test results and referrals, including urgent and cancer related work, placed people at risk of delayed diagnosis and harm. Safeguarding systems were ineffective, with inaccuracies in registers, missing alerts and incomplete training. This placed people at risk of delayed diagnosis and harm. The practice did not have a strong learning culture; incidents were underreported, poorly reviewed and learning was not embedded. During our assessment in September 2025, we found improvements in several high-risk areas, including pathology backlogs, safeguarding, risk areas and emergency equipment. However, these improvements were not yet fully embedded and further action was required to ensure people were reliably protected from harm.

The practice was in breach of legal regulation in relation to safe care and treatment and the service has been rated requires improvement for providing safe care and treatment.

This service scored 47 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

When we carried out our assessment in April 2025, we found the provider did not have processes for staff to report incidents, near misses and safety events. There was no positive safety culture based on openness and honesty. Leaders did not listen to concerns about safety, safety events were not reported or recorded and lessons were not learnt to identify and embed good practice.

We also received several concerns that staff were discouraged by leaders from raising significant events and those who did so would be dismissed. As a result, we found some incidents had not been reported, including 4 serious incidents which hadn't been identified.

We found significant event meetings were not being held at least quarterly as recommended, so opportunities to learn from events were missed. The practice held only 2 meetings in 2024 and none in 2025. There was no formal policy outlining how significant events should be reported, reviewed or discussed.

During the April 2025 assessment, we also found there were inadequate systems in place to monitor and act on medicines safety alerts. The practice told us they were disseminated in the practice but we were not assured they were being monitored. For example, the Medicines and Healthcare products Regulatory Agency (MHRA) published a drug safety update in 2014 advising the medicine combination of clopidogrel and omeprazole should not be prescribed together, as omeprazole reduces the effectiveness of clopidogrel and places the patient at an increased risk of a stroke. Searches of the clinical records system found 15 patients prescribed this combination of medicine; all of whom had not been reviewed.

Following the April 2025 assessment, the provider responded promptly with an action plan detailing steps to address the concerns identified. Further assessment activity in September 2025 found the system to monitor drug safety alerts had improved.

The further assessment activity showed the practice had implemented a new system to capture and monitor incoming safety alerts; however, the evidence provided showed only alerts since January 2025 had been captured, including 2 from 2019 and 2023. We discussed our findings with the practice who told us they had completed a review of the relevant existing and previously issued MHRA safety alert searches with actions being taken by the clinical team. Work was ongoing to ensure all necessary patient reviews were completed.

Further assessment activity found there were no patients prescribed SGLT2 inhibitors (medicines used primarily to treat type 2 diabetes, heart failure and chronic kidney disease) who had not received education on the risks of ketoacidosis and Fournier’s gangrene. The majority of the previously issued and existing MHRA alerts did not identify any patients currently at risk. However, the search results continued to show issues with the practice’s recognition and application of MHRA drug safety alerts.

We also saw evidence that a clinician had overlooked the MHRA alert concerning the interaction between omeprazole and citalopram, despite this being highlighted within the patient’s record. The practice told us that the practice pharmacist was aware of the relevant alerts; however, the management and oversight of these alerts lacked sufficient clinical insight and mandatory risk discussions had not consistently been held with patients.

During the September 2025 assessment activity, we requested evidence from the practice to demonstrate how their learning culture had improved. We found there had been only some improvements as the documentation provided by the practice was inconsistent and lacked clarity. Significant event forms were unclear and did not follow a consistent structure. The practice submitted 3 different versions of significant event analyses, alongside minutes of meetings recorded in a way that made it difficult to identify the incidents or any resulting learning.

These findings were consistent with feedback from clinicians, who reported an absence of effective processes to support learning from incidents.

Our April 2025 assessment found the service did not maintain safe systems of care. They did not manage or monitor people’s safety, or make sure there was continuity of care, including when people moved between different services. We received concerns regarding a significant number of documents, referrals and test results were not managed in a timely way.

When we carried out the inspection in April 2025, we reviewed the practice’s document management system and found 7,319 tasks not actioned, with the oldest dating back to November 2024, which included palliative care patients. Staff attributed this backlog to severe staffing shortages and were trying to clear the backlog. We noted that staff previously responsible for coding had been reassigned, creating gaps in document management processes. These failures resulted in overdue prescriptions and medicines reviews and the practice had placed a hold on booking further reviews due to capacity constraints. Staff were not being supported to ease the backlog.

We also saw 22,500 documents remained unprocessed, 1,593 tasks were outstanding on the clinical system, some were urgent tasks from May 2024 which had not been completed. We also saw 570 referrals were still awaiting processing and could not confirm that urgent 2-week wait referrals were not among these delays. We were told there was a 4-month backlog with all the urgent and 2-week wait referrals. There were also no systems in place for monitoring the 2-week wait referrals and we saw examples where these referrals had not been marked as urgent and so had been missed in the long list of tasks awaiting action. The backlog placed patients at risk of harm from missed diagnosis and delayed treatment.

Our review of the clinical system also identified 2,382 unactioned pathology results, with the oldest dating back to April 2023. The practice did not have an effective system in place to ensure patients were informed of and action taken on their blood test results. This put patients at risk of harm from missed or delayed referrals and delayed treatment.

We received a high volume of patient complaints sent to CQC that were consistent with our findings and observations on assessment and with online feedback. The common key issues from the complaints related to patients not being informed about abnormal results, inconclusive samples or repeat tests required, delays in the processing secondary care letters for up to a year and patients needing to come in person for simple queries, due to unanswered phones or email access issues.

There was no prioritisation for cancer referrals and there were delays in informing patients of the outcome of their cancer referrals investigation results, with one patient having to wait 2 weeks to be informed of their result. GPs reported concerns that during telephone medication reviews, patients frequently requested discussions about their test results. These requests arose because patients had been advised to book follow-up appointments but were unable to secure one despite repeated attempts. This issue affected a significant number of patients.

Following the April 2025 assessment, the provider responded promptly with an action plan detailing steps to address the concerns identified.

Further assessment activity in September 2025 found the practice had implemented their action plan to address the backlog issues and improve timely communication with patients. The practice had identified that the majority of the backlog of unprocessed pathology results was due to how results were assigned to individual clinicians. Action was taken to improve blood test management, with daily result reviews and a buddy system in place to ensure continuity when clinicians were absent. Locum staff were employed to allow the GP partners to complete the outstanding pathology results reviews and actions.

As a result, the number of pathology results had reduced from 2,382 to 1,225 within 2 weeks of the April 2025 assessment and the practice was in the process of reducing them further. At our further assessment activity in September 2025, we found significant improvements had been made and all previous outstanding pathology results had been actioned.

A Docman risk assessment was also carried out, a healthcare assistant was engaged and document management was outsourced to a specialist external company in order to review, action and clear the documents backlog. Additionally, the practice recruited a GP dedicated to managing Docman tasks remotely and they amended the non-clinical roster to ensure documents were actioned daily, coding staff were returned to their roles and additional Docman training was provided.

As a result of these changes, in September 2025 we found document management had improved and reduced from 7,319 to 3,965 tasks in all folders with none of those tasks unactioned. Documents requiring filing had reduced from 22,500 to 439 and further to 42 in December 2025. The number of unactioned tasks had reduced from 1,593 but still high numbers with 634 unactioned tasks, including 208 high priority items.

We also found improvement in how the practice monitored their urgent cancer referrals. The practice introduced a cancer referral policy and process which included weekly system searches, referral tracker and routine audits. Audit findings and monitoring outcomes would be discussed with the lead GP at clinical governance meetings. However, we were not provided with a copy of their referral tracker to review when we requested this information after the assessment.

The practice had 150 patient notes pending summarisation. A summariser was recruited and 100 notes remained outstanding in September 2025.

A new appointment triage system for up to 60 appointments per week was introduced, which improved access for patients but increased clinical and administrative activity. Additional follow up work created by the backlog to support secondary care referrals also contributed to rising task volumes, this was mitigated with the introduction of additional locum clinicians. A structured allocation system to address the backlog of unactioned correspondence was introduced. Each GP was assigned up to 250 Docman tasks per week, enabling the team to process approximately 1,000 tasks weekly. Regular monitoring by the practice manager and clinical leads ensured timely actioning of clinically urgent and high-risk correspondence, this resulted in improved governance and reduced risk to patients.

As part of the assessment, we requested feedback from the 3 care homes supported by the practice. One home reported no concerns with the systems and pathways in place for their residents. However, another home described delays in registering new residents and in obtaining referrals to the mental health team, although they noted some recent improvement.

At the assessment in April 2025, we found the practice had inadequate safeguarding processes. The system in place did not provide assurances that all patients at `risk were captured and reviewed to safeguard them from abuse and harm. The provider could not say how many children were under a child protection plan and when we reviewed one of their patients on the safeguarding register, we found there was no alert on their records and the family link was not added to their record.

The adult safeguarding list only showed 25 adults, 13 of which the reason for being on the safeguarding register was not recorded. Three of these entries had children who were under child protection orders but who were not recorded on the register.

During the assessment, we identified significant concerns regarding the management of children with mental health needs. We found that 77 out of 298 children aged 5 to 15 years had been placed on the mental health register without a valid clinical reason and had not been reviewed. In addition, 157 children with identified mental health issues had not been followed up or referred to appropriate services.

Staff were not up to date with their mandatory training, including safeguarding training due to workload pressures and lack of time to complete it.

Staff also reported significant challenges in getting GPs to complete safeguarding responsibilities, including uploading forms via a new online portal, and expressing frustration at the lack of accountability and willingness to assist. The GP safeguarding lead, although aware of the situation and with some cases dating back to early April 2025, had not taken action.

Following the April 2025 assessment, the provider responded promptly with an action plan detailing steps to address the concerns identified.

Further assessment activity in September 2025 found some improvements in safeguarding processes and risk management systems. The lead GP had recently reviewed and updated the child protection policy and introduced a comprehensive, combined safeguarding handbook with all the relevant details, including named leads and escalation details.

They had also improved in the recognition of vulnerable and at-risk patients through case finding exercises and ensuring coding was correct and up to date. We cross referenced 1 young child with the safeguarding registers and saw this patient had been highlighted as at risk. On assessment, the practice was able to demonstrate how a vulnerable patient concern sent to CQC was managed in a timely manner.

The practice had also worked with the ICB’s designated safeguarding lead to identify their vulnerable patients and worked with the health visitor to identify children under 5 years of age who were at safeguarding risk. School nurses were also contacted for their input.

As a result, we saw an increase in the number of patients being identified as at risk or vulnerable and placed on the registers. The safeguarding data submitted by the practice showed a significant improvement in safeguarding identification and coding between April and October 2025. For example, the number of vulnerable patients flagged under mental health rose from 448 to 476, while vulnerable adult and child codes increased from 949 to 1,147. We also saw evidence of family links added to child protection registers.

While we saw evidence of safeguarding discussions with health visitors, our review of meeting minutes showed only 2 meetings in the past six months were held where safeguarding was discussed, one of which was a staff information session held in July 2025. There were no dedicated adult or child safeguarding practice meetings recorded and safeguarding was not listed as a standing agenda item. This lack of oversight increased the risk of vulnerable patients not being identified, monitored or protected from harm.

Our review of safeguarding training records in September 2025 showed that all but one non-clinical staff had completed the required adult and child safeguarding training with 8 out of 13 clinicians compliant. This gap in compliance means some staff may not have the necessary knowledge to identify and respond to safeguarding concerns, which could compromise patient safety. Clinicians had also received the safeguarding portal access and training following staff feedback.

As part of the September 2025 assessment activity, we requested an update from the practice regarding the 157 children on the mental health register that had not been reviewed and some who had been placed on the register without a valid reason. The practice told us all these patients had been followed up and reviewed. However, we did not see clear evidence of this in the information submitted by the practice.

Prior to the assessment in April 2025, we received concerns that people using the service were being placed at significant risk of harm and a breakdown of the leadership in the practice meant risk was not being managed safely.

We found not all staff were aware of the actions to take in a medical emergency and there were gaps in staff emergency training records.

We found inadequate systems including emergency equipment and medicines checks. We found out of date and missing equipment. We also found out-of-date emergency medicines and there was no evidence of regular checks of emergency medicines and equipment. We also found adrenaline was not stocked in all rooms where vaccines were administered, which was not in line with guidance. The lack of reliable systems for checking and maintaining emergency equipment placed patients at significant risk of harm and the absence of regular checks meant the provider could not be assured that lifesaving equipment was safe, functional or available when needed, increasing the likelihood of delayed or unsafe responses during medical emergencies.

Following the April 2025 assessment, the provider responded promptly with an action plan detailing steps to address the concerns identified. Steps included holding a business meeting with all staff to discuss emergency procedures and staff were reminded of how to recognise a deteriorating patient and the actions that should be taken.

During further assessment activity in September 2025, we reviewed the systems in place to ensure patients under 5 years old, as well as deteriorating patients, were not turned away from the practice. The provider had implemented a policy requiring same-day appointments for these groups. The duty GP was responsible for ensuring these patients were seen promptly and additional appointment slots were created when routine availability was exhausted.

We found evidence of improved emergency procedures in relation to 2 reported incidents that we reviewed where people displayed red-flag symptoms and required urgent care. For example, when an individual fell ill within the practice with suspected red flag symptoms, we saw that timely assessment and management of this medical emergency we saw evidence of effective teamwork in action to ensure the individual was safely assessed and taken to the hospital. Following this incident, the practice implemented further protocols and guidance for staff, which included supporting staff through informal debriefs and wellbeing check-ins.

The practice recognised reception teams played a vital role in the early recognition and escalation of potential emergencies, following the management of a patient presenting with chest pain at the practice. An analysis of this event through a practice discussion highlighted that although the clinical response was exemplary, front-line triage guidance should be standardised and refreshed regularly. The reflection also emphasized the value of cross-team communication and ongoing joint training to strengthen safety culture.

However, there continued to be significant gaps in staff training. Not all clinical and non-clinical staff were up to date with essential training, including anaphylaxis, sepsis and basic life support. These gaps meant the provider could not be assured that staff had the appropriate knowledge and skills to respond safely and effectively in an emergency in relation to medicines and equipment.

The practice had carried out a resuscitation audit to review its emergency medicines and equipment. The practice was able to demonstrate that emergency medicines and equipment checks were taking place on a regular basis.

They had taken most of the required steps and actions to ensure there was an effective system in place to manage emergency equipment; for example, out of date equipment had been replaced with in date stock which was monitored weekly. Paediatric defibrillator pads had been replaced and were stored appropriately on the emergency trolley, with regular checks in place. Adrenaline and rectal diazepam were available, in date and monitored weekly. We noted that adrenaline would require monitoring as it was due to expire in January 2026 and further action was required to ensure the adrenaline was stored in all rooms where vaccines were administered.

Prior to the inspection in April 2025, we received concerns regarding the health and safety arrangements in the practice which were consistent with our findings on inspection. When we carried out the initial site visit in April 2025, we found the practice did not have adequate systems in place to ensure the care environment was safe. For example, the fire safety procedures did not always detect and control potential risks. The practice fire risk assessment was last carried out in January 2022 and was overdue a review since January 2023, fire extinguishers were last serviced in November 2023 and were overdue servicing since November 2024, fire alarm testing was not recorded and had not been carried out since 2024. Not all staff were up to date with fire safety training and designated fire marshals had not received specific training.

There were no health and safety audits carried out to identify and mitigate risks. We observed number of risks including a broken seat in the disabled toilet and a broken privacy screen.

We found cleaning product risk assessments and data sheets were in place in line with Control of Substances Hazardous to Health (COSHH) arrangements. However, monitoring was not effective as hazardous materials were not securely stored and were accessible to patients.

The practice did not have any legionella safety systems in place. We did not find any evidence of water temperature testing and there was no evidence of water flushing of the showers inside the building. Legionella risk assessments had not been carried out. Poor management of Legionella risks in water systems can have serious health consequences, including loss of life.

There had been no portable appliance testing (PAT) and calibration of medical equipment since 2023. As a result, the provider did not have oversight of all electrical safety risks and medical equipment may not have provided accurate readings, potentially affecting diagnosis and treatment. Fixed electrical system testing took place in 2021 and was still in date.

Following the April 2025 assessment, the provider responded promptly with an action plan detailing steps to address the concerns identified.

Further assessment activity was carried out in September 2025 to assess progress and we found improvements had been made. We saw that outstanding risk assessments such as the legionella, fire, COSHH and health and safety risk assessments had been carried out in May 2025 and recommended action plans had been completed. Systems were now in place for all premises checks to be logged on the system with a diary reminder to renew these annually or at the appropriate intervals. There were also systems in place to ensure equipment, including fire safety equipment was serviced and annual maintenance carried out. Equipment calibration and PAT testing was carried out in May 2025 and the practice told us faulty equipment was removed and replaced. The practice needed to ensure all external risk assessment documentation was signed or dated by a site representative.

However, we found continued gaps in the management of fire safety. The practice was unable to provide a fire safety policy or a health and safety policy, which meant we could not verify whether required fire drill intervals were being met. Although weekly fire alarm testing was taking place, the last recorded fire drill occurred in March 2025 and was due within 6 months.

Three staff had completed their fire warden training; however, we found significant gaps in fire safety training, 13 out of 31 staff had not completed or were not up to date with their training. There was no evidence of any health and safety training for staff.

There was a detailed business continuity plan in place which was monitored and reviewed. Staff were told what to do in a non-medical emergency and had access to the practice’s business continuity plan.

The practice had 2 branch surgeries which were not visited as part of this assessment as there were plans in place to close these sites and they were not accessed by staff or patients.

Prior to our assessment in April 2025, we received significant concerns regarding staffing challenges at the practice. Staff reported inadequate staffing, support, supervision and development opportunities. They also highlighted that some individuals were working beyond their scope of practice and competence, placing patients at risk of harm.

Clinician resignations were attributed to unsafe working conditions. At the time of inspection, the workforce had reduced from 11 GPs to 2 GP partners supported by locum GPs. Concerns were also raised regarding 13 departures from the practice in the past year, including administrative staff and management team. This resulted in limited appointment availability which compromised patient care, as roles were not replaced. This caused considerable pressure on the remaining team and contributed to reduced staff morale, as staff had to assume additional responsibilities beyond their usual remit.

These concerns were consistent with our findings during our April 2025 assessment. There were not enough staff and the provider could not keep patients safe. Staff were overworked, with significant workloads and a lack of time made available to undertake administrative tasks such as document management. There was no permanent practice manager at the time of the assessment.

The practice did not have sufficient clinical capacity to meet patient demand and this was supported by patient feedback. As part of the assessment, we looked at the number of clinical sessions provided in the practice. The GP partners provided 6.5 and 4 clinical sessions per week respectively. Only 5 urgent appointments were available each morning and each afternoon. Staff had raised concerns with the partners that having to provide extra consultations created an unsafe workload and they were regularly working the equivalent time of two sessions instead of one to provide safe care. There was no management structure and there was a lack of communication with staff. On one occasion, a locum GP did not arrive for their scheduled clinic and 5 patients were waiting. Staff weren’t aware of this situation, who to report to or what to do. These staffing shortfalls meant the practice did not have sufficient clinical capacity to meet patient demand. We saw that staff consistently raised concerns with the partners that multiple extra consultations created an unsafe workload and they were regularly working the equivalent time of two sessions instead of one to provide safe care.

Additional staff were present on the day of assessment due to overtime arrangements; however, staff also noted there was high sickness absence on the day of assessment. Normally, the practice operated with minimal staffing; for example, 2 receptionists at the front desk, up to 2 staff managing calls and 1 staff member for triage.The arrangements for sickness cover were such that important administrative tasks were often neglected in favour of patient facing positions such as phone and front desk roles.

Staff felt unsafe to continue working in the practice without the partners acting on the concerns raised. Staff working beyond their competencies had prescribing errors, provided inappropriate treatments, inappropriate investigation requests and inadequate assessments and documentation. For example, some reception staff were completing clinical triage with no formal training, putting patients at risk and increasing workload for GPs who needed to review requests to check if they were safe and appropriate. This was consistent with patient complaints that they were told by non-clinical staff that their test results looked fine when they were not. GPs suggested to partners that such staff required teaching, supervision and a set criterion to work to but this was not provided. Concerns were also raised that home visits were not being documented by some staff, with one not documented until a week after the visit, by which time the patient had deteriorated and was admitted to hospital. Staff felt the lack of supervision and support meant such errors were taking place.

Support for staff was minimal, with limited engagement from leadership and no structured oversight. Administrative roles were changed without appropriate consultation or training, resulting in staff undertaking tasks beyond their competence. Training provision was inadequate, out of date and with some staff telling us they were largely self-taught for key responsibilities such as Quality and Outcomes Framework (QOF) management, appointment scheduling and clinical system searches. One staff member was also asked to complete an external course at their own expense without reimbursement, highlighting gaps in staff development support.

We did not find any evidence of a supervision protocol for paramedics recruited in the practice. We observed roles such as those of the Physician’s Associate fell outside of the national guidelines. We were not provided with any evidence of how their supervision was managed. We also found meetings were not taking place prior to the assessment in April 2025. Staff told us there used to be huddles and weekly training but this had now stopped due to not enough having enough staff.

Following the April 2025 assessment, the provider responded promptly with an action plan detailing steps to address the concerns identified. Further assessment activity in September 2025 found the practice had taken steps to improve staffing in the practice. The practice received support from a locum practice manager until they recruited an experienced full-time practice manager in September 2025.

Following the April 2025 inspection, 2 new salaried GPs were appointed with a view to partnership, alongside 6 locum GPs, a summariser, a pharmacist, 2 reception and administrative staff, a healthcare assistant, a prescription clerk and a dedicated GP responsible for managing Docman tasks. Two GPs had begun supervising trainees, strengthening clinical oversight, 2 salaried GPs were scheduled to join in March 2026 and a GP trainer commencing part-time. Two GPs had begun supervising trainees, strengthening clinical oversight.

One staff member had returned to the practice and some existing staff had increased their contracted hours. One salaried GP had increased their clinical sessions from 5 to 8 sessions per week and practice data showed there were currently 10 GPs providing a total of 52 clinical sessions per week.

Reception staff undertaking clinical triage now had the role of care coordinator assisting the duty doctor with triage and did not work alone. We were told that role specific training was planned however, there was no evidence provided of this.

Gaps remained in all aspects of mandatory training, staff appraisals and revalidation, risking staff competency, oversight and quality of care.

The service did not always assess or manage the risk of infection.

The annual infection control statement, updated in January 2025, contained conflicting information about the designated clinical leads. It also stated that a legionella risk assessment had been completed, although this was inaccurate, as the first documented assessment was completed in May 2025.

Our further assessment activity in September 2025 showed the practice had a designated infection prevention and control lead. There was an infection control policy and needlestick injury policy which were both reviewed in August 2025. We observed the premises, including the new building extension, to be clean and tidy with clear walkways.

Infection control training records showed gaps for both non-clinical and clinical staff with incomplete or overdue training.

We observed infection control guidelines were not always followed. For example, mops were stored in a way that created a risk of cross-contamination. Similarly, cleaning cloths were left overlapping on a shelf to dry, instead of being stored separately and allowed to dry fully to minimise contamination risks. Action was taken after our assessment to reduce the risk of cross contamination.

An environmental cleanliness audit had been carried out in September 2025; however, we were not assured that all identified actions had been completed, as further evidence was not provided. A hand hygiene audit had been completed. A cleaning checklist was available for only 3 clinic rooms and there was no evidence that a full infection control audit had been undertaken.

We did not assess clinical waste arrangements at this assessment; however, the infection control policy included information about the safe handling and disposal of clinical waste.

Our April 2025 assessment found that medicines were not managed safely. There was no effective system for medicines reviews and limited appointment availability meant GPs often had to call patients to complete overdue clinical reviews, creating additional unplanned consultations. Staff shortages contributed to delays in processing prescriptions which were not always authorised on the same day as issue, with some prescriptions waiting more than a week. There wasn’t always an effective clinical review before authorisation, including for high-risk medicines prescriptions. Blood tests and monitoring required to support safe prescribing was not always completed. This put patients at risk of harm.

During the April 2025 inspection, both clinical and non-clinical staff confirmed waiting times for prescriptions were a concern. The practice’s prescription processing capacity had reduced which resulted in increased administrative pressure and contributed to delays in prescription processing, creating a risk that tasks were not completed within the required timeframes. Despite assurances from leadership that improvements would be made when these same concerns were raised with them 6 weeks prior by staff, the situation remained unchanged, leading to staff withdrawing from the practice citing an unsafe working environment.

We found prescriptions pending for over a week, which meant some patients ran out of essential medicines, leading to complaints. Staff attempted to mitigate delays by printing prescriptions for same‑day GP signature but this workaround was stopped.

The management of long-term medicines prescribing was also not safe including for patients prescribed disease-modifying antirheumatic drugs (DMARDS) who required monitoring due to the risk of serious side effects. Our searches of the practice clinical system identified 11 out of 64 patients prescribed methotrexate had not received the required monitoring in the last 6 months. We reviewed a sample of 5 of these patient records and found all patients were overdue monitoring and none had shared care agreements. One of these patient’s last test showed abnormalities and dosing instructions were unclear. Repeat medicines and alerts were inconsistently updated for 3 of these patients. This put patients at risk of dosing errors and unsafe prescribing.

Searches identified 10 out of 21 patients prescribed Azathioprine that had not received the required monitoring in the last 6 months, placing them at risk of serious side effects from the medicines they were taking.

Our review identified significant risks in the management of patients prescribed ACE inhibitors. Searches for patients prescribed ACE inhibitors showed 181 of 1,731 patients had not received the required monitoring. We reviewed a sample of 5 of these patients and found that 4 were at increased risk due to overdue tests, including 1 elderly patient with additional comorbidities.

Our searches found 48 out of 467 patients prescribed direct oral anticoagulants (DOACs) had never had a creatinine clearance calculated and 245 out of the 467 patients had not had one in the last year. These gaps in monitoring meant the provider could not assure us that people were protected from potential harm.

Medicines safety alerts issued by the MHRA were not always managed safely. We found the MHRA warned in 2019 that SGLT2 diabetes medicines can cause rare but serious infections such as Fournier’s gangrene and diabetic ketoacidosis, advising clinicians to ensure patients are informed about these risks when starting treatment, during reviews, or in written information and when to seek urgent medical help. Our search identified 277 patients to whom this advice should have been applied. There was no documented evidence that 3 of the 5 patient records we reviewed had been advised about the risks of Fournier’s gangrene or DKA, despite relevant alerts being present in their records.

We looked at benzodiazepines, prescribed for short-term relief of severe anxiety. Of 112 patients prescribed benzodiazepines, we reviewed a sample of 5 records and found that all 5 did not have a documented warning of addiction risk in their records and 3 did not have documented wean down advice in their records.

Prescribing data reviewed as part of our assessment showed the number of antimicrobials issued by the provider was comparable to local and national averages, however, there was no programme of regular clinical audits of prescribing that focused on improving care and treatment.

Prescription stationery was not managed appropriately and securely to reduce the risk of loss or misuse. We observed several open boxes of blank prescriptions stored in an accessible area of the practice. Staff confirmed no checks were currently in place with sporadic records only available from 2018 and 2019. The practice moved the boxes to a more secure area and arranged for the collection and removal of the boxes; however, we were not provided with evidence to confirm this.

When we reviewed the practice cold chain monitoring processes, we found that vaccines were being inappropriately stored in sample fridges, which were not designed to safely store vaccines. There was no evidence that daily temperature monitoring was taking place, creating a significant risk that temperature breaches could go undetected. We also observed vaccines were also stored in direct contact with the sides of the fridge, reducing airflow and affecting temperature control. Improper storage and inadequate temperature monitoring can compromise vaccine effectiveness.

Following the April 2025 assessment, the provider responded promptly with an action plan detailing steps to address the concerns.

Further assessment activity in September 2025 showed the practice pharmacy team worked in collaboration with the GP partners to create a strategic action plan addressing the findings from the April 2025 assessment. This action plan, updated by the team several times each month outlined remedial actions completed to date, progress in mitigating identified risks and a structured, time-bound framework for ongoing implementation. High-risk areas such as medicines managed were prioritised through enhanced pharmacist capacity and systematic monitoring.

As a result, we found improvement in the management of medicines as numbers of patients overdue monitoring had reduced; however, further improvement was required to ensure all patients were up to date with required monitoring and review and that improvements were embedded.

We found the practice had 65 patients prescribed methotrexate and that although most methotrexate monitoring had improved, 1 person was overdue monitoring and 1 still lacked a coded shared care protocol. None of the 5 reviewed cases had methotrexate prescribed in line with MHRA fixed day, creating a risk of dosing errors.

Of the 1,691 patients prescribed ACE inhibitors, 31 were overdue the required monitoring. We reviewed 5 records and found 4 patients were low risk. One patient was higher risk, having not had a blood pressure check since January 2023 and presenting with other co-morbidities.

When we looked at direct oral anticoagulant (DOAC) monitoring we found there were no patients who were outstanding for creatinine clearance; however, there were 24 out of 294 patients aged over 75 years old who were not having the required monitoring.

The number of patients prescribed benzodiazepines for short term relief for anxiety had increased by 3 since the April 2025 assessment to 115. Of the 3 patient records we reviewed, all were also prescribed multiple antidepressants or other sedating psychotropic medicines, increasing their risk of dependency. Some patients had been prescribed benzodiazepines for 20 to 40 years. Although all 3 patients had documented medicines reviews, only 2 had evidence of a tapering or weaning discussion. All 3 had been advised about addiction risks. One patient had additional risk factors due to age, frailty, polypharmacy involving sedating and controlled drugs and long-term diazepam use dating back to 1991. This case demonstrated the need for strengthened oversight and structured monitoring of high-risk patients.

We found the practice had generally improved their management of HbA1C results and follow up. They followed the national guidance of repeating average blood sugar levels above 47 within 2 to 12 weeks, whereas this was not carried out prior but was now standard practice. Our searches identified 18 patients with a potential missed diagnosis of diabetes. We sampled 5 patient records, however, 4 of the 5 patients had not been informed of their abnormal blood test results.

Two patients were identified as having polypharmacy (more than 10 prescribed medicines) without a medication review in the last 18 months. Both were at risk due to gaps in follow up and clinical oversight; for example, a hospital discharge letter advised stopping 2 medicines for 1 patient but this was not actioned. Another patient with diabetes whose significantly abnormal blood test results had not been addressed since their initial identification. The findings suggested likely progression of diabetic complications due to the absence of appropriate monitoring and intervention.

We found 78 of the 247 patients prescribed gabapentinoids (high risk medicines that require regular monitoring due to the potential for dependency and misuse) had not received a medicines review in the last 12 months. Whilst the practice had begun implementing an action plan to improve medicines optimisation, further improvements were required to ensure all patients received regular and appropriate monitoring.

We received concerns that changes to mental health medicines were not consistently documented in patient records and patients reported repeated delays in obtaining essential medicines, despite previous dosage adjustments being clinically justified. On one occasion, a patient was advised they would receive a call back but this did not occur, leaving them without medication and at risk of harm. These concerns were consistent with our findings on inspection.

Our clinical record searches showed that where medicine reviews had been recorded as being carried out, not all showed documentation about the review. Of all the records we sampled across the various population groups, we found at least 9 of the medicines reviews did not contain details about the review itself and they were also not coded as medicine reviews. This placed patients at potential risk from the medicines they were taking.

We requested feedback from the 3 care homes supported by the practice. Overall, while routine medicines processes were now more reliable. The homes described past delays, particularly with urgent prescriptions which occasionally led to safety concerns but overall, routine medicines processes were now more reliable and improvements such as earlier GP visits and paper prescriptions when needed, had resulted in fewer delays.