Castlegate & Derwent 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 requires improvement. At this assessment, the rating has changed to inadequate.

The service was in breach of legal regulation in relation to safeguarding systems.

This service scored 38 (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. Clinical leaders did not listen to concerns about safety and did not always investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

People felt supported to raise concerns to the significant event leads. At the time of inspection, the practice had 2 staff members who took responsibility for significant events. We were made aware during our inspection that these 2 members of staff intended to step down from this role. Since our inspection, we have been made aware that new significant events leads are in place, we will review this at out next inspection.

Despite accurate reporting of events from staff, clinical leaders did not always take appropriate action. We observed recurring themes from significant events with no action being taken. For example, it had been reported in June 2025 that more than 1,000 diary dates required action.Diary dates are reminders in a computer system, for appointments such as x-rays, blood tests or scans. These remind the provider to action. Leaders had not actioned this and at the time of our inspection, had no plan to do so.

Staff did not feel there was an open culture, and that safety was not a top priority. We saw examples of staff approaching clinical leads with concerns regarding the triage of patients, and these had been dismissed.

The provider had processes for staff to report incidents, near misses and safety events. Staff followed this process. Learning from incidents and complaints did not result in changes that improved care for others. We reviewed significant events which were of the same theme as our previous inspections. This was despite leaders telling us they would attempt to implement learning and changes to practice.

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 well. They did not make 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. We observed a lack of consistent communication between primary and secondary care. Clinical leaders told us that amongst the 1,000 patients with an overdue diary date, they were unaware who’s care was being managed by secondary care services.

Referrals and test results were not always managed in a timely way; this was due to staffing levels and a lack of effective processes. Clinical and non-clinical leaders provided us with a different overview of how test results were managed. Patients told us that they had to chase results, and we saw examples of patients who were told to contact the surgery. When they did, reception staff did not always know the reason for this, causing a delay in care.

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

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. Staff told us safeguarding meetings were infrequent. Staff also told us that safeguarding processes in the practice were not sufficient and that they did not fully understand the process. Safeguarding meetings were held but only attended by one clinical and one non clinical member of staff, minutes were not concise and were challenging to interpret. This raised concern over how concerns were shared with staff, who were not attending meetings. Minutes did not provide enough contextual information to provide clinicians with an understanding of what risk of harm was present for each patient. Leaders told us safeguarding was discussed at multi disciplinary team (MDT) meetings, we were not provided minutes of these meetings.

The practice maintained a list of vulnerable people however there was limited evidence of working with external organisations.

During our inspection we saw in excess of 500 people who had been triaged by an external provider. It was unclear if this provider had checked any safeguarding concerns during this process. We saw examples of patients who were at risk of harming themselves due to mental health being triaged with a potential wait of 4 weeks for an appointment.

The service 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.

Emergency equipment was available and maintained. Staff could recognise a deteriorating patient and knew of action to take.

Patients were not always advised on risks related to their condition and actions to take if their condition deteriorated. We saw examples of online triage forms which did not safety net patients appropriately. For example, a patient completing a consultation around mental health was not provided with information to enable them to contact crisis teams.

The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. Some staff told us they did not understand the process for fire safety within the building relating to staff working alone or after hours. We reviewed training documents which demonstrated clinicians were not up to date with some elements of training relating to safe environments. We reviewed an incident where a member of staff had been in the building and no one was aware. This was a risk in the event of a fire. Staff raised concerns with regard to lone working. We were made aware of incidents where staff had been the only person in the building. Non Clinical Management have told us since our inspection, reception staff will no longer work alone. This will be reviewed at our next inspection.

Contracts were in place to ensure the premises were maintained. Health and safety risk assessments and audits had been undertaken and risks identified had been addressed. 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. 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 were a range of clinical and non-clinical roles within the practice. We found mandatory training was up to date, learning needs and development of staff was managed appropriately, however we saw that staff members were not always supervised appropriately. Supervisors told us they were unsure of the roles of staff they were monitoring. We saw instances where staff were working unattended in the building leading to circumstances which meant patients did not have access to a chaperone if they requested one. We noted that reception staff were expected to work alone, despite incidents of abuse from patients. Since our inspection we have been advised the practice had implemented a policy whereby 2 members of staff will be on reception at all times.

Staff told us that they felt staffing levels were unsafe. We saw safe recruitment processes for permanent staff. However, some locum GP’s who had previously worked in the practice had not provided recruitment documentation before commencing shifts. We did not see evidence that DBS checks and references had been provided ahead of the first shift, and had been requested retrospectively.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. Staff knew who the infection control lead was. We reviewed audits being carried out appropriately.

The practice had a designated infection, prevention and control lead and all staff had had relevant training. Cleaning schedules were in place and followed. Risk assessments and actions taken to mitigate risks.

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.

Safety alerts were reviewed by a clinician and shared appropriately with staff members. However, there had not been an audit carried out to ensure that patients who had been indicated in an alert had been contacted or been prescribed alternative medications. Leaders told us a newly employed pharmacist would take up this role, we will review this at our next assessment.

Not all staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely. People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms. However, due to current staff capacity this could mean a long wait. We saw examples of patients waiting up to 4 weeks to be contacted.

We reviewed 5 records for patients who had a medication review coded in the last 3 months. All 5 records had a medication review coded but none had involved the patient or had any records made to show that patient’s notes had been reviewed. We also looked at patient records for people who were being prescribed numerous medicines (polypharmacy). Polypharmacy is the concurrent use of multiple medications (often defined as 5 or more) by a single individual. Three out of the 5 patients we looked at in detail had not had their medicines reviewed since 2021. The other 2 patients had not had their medicines reviewed since 2022. This meant we could not be assured medicines were being prescribed safely.

Staff managed prescription stationery appropriately and securely.

Medicines including controlled drugs were stored securely and at appropriate temperatures. Nursing staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines, vaccines, and controlled drugs.

We reviewed prescribing processes, it was unclear how leaders wanted this to work. We were provided conflicting information regarding how many re-issues were within the process. It was unclear which partner had taken responsibility for prescribing, the previous lead had left the practice.

We reviewed an audit of non clinical prescribers, that had taken place in January 2026. This was a clear overview and review of prescribing themes and trends. The clinician who carried this out had since left, during our assessment leaders gave us conflicting information on how this would continue, in relation to frequency and which clinician would take ownership.