Glenroyd Medical

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.

Learning culture was not embedded to promote openness and ensure lessons were learned. Incidents were not always investigated thoroughly. Not all the required staff checks took place. We found issues with the management of medicines. The facilities and equipment did not meet the needs of people. Risks had not been identified by the provider and so had not been mitigated. Managers could not demonstrate that staff had received appropriate training.

At our last assessment, we rated this key question as good. At this assessment, the rating has changed to inadequate. The practice is in breach of legal regulations in relation to safe care and treatment, and fit and proper persons employed.

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 practice 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 learned to continually identify and embed good practice.

The practice provided us with their significant/critical event policy. This was undated. The policy listed examples of what should be reported, for example, new cancer diagnoses, deaths where terminal care has taken care at home, health and safety issues or incidents and events that had resulted in a complaint. We could not find any evidence to demonstrate that such events were recorded as significant events. The policy did not reflect the current system; it stated a form should be completed and passed to the practice manager. However, the business manager told us they had a new system where a Microsoft form was completed to capture all information, and this was automatically transferred to a spreadsheet to be dealt with and monitored. The spreadsheet started in August 2023. However, the business manager provided us with 2 significant event forms from April 2024 that had been completed using the old system. These were held separately so were not monitored. The business manager told us the system was a ‘work in progress’.

We were given examples of 2 significant events, but these were not recorded on the spreadsheet or on the old system. For 1 of these the business manager told us they could not remember if they formally recorded it. For the other they had instructed a staff member to complete the required form but acknowledged it could not be located and had not been added to the spreadsheet.

We examined a significant event regarding a medicine error. The person’s records did not reflect that an error had taken place or that the person had been informed of the error, and there was no evidence of any discussion regarding the potential risk to the person or any required learning.

The business manager told us it could take a while to review significant events as they had to decide what to discuss in meetings. Minutes from the practice meeting on 2 April 2025 showed that significant events from 15 November 2024 and 29 November 2024 had been discussed. There had been 6 significant events recorded between then and the meeting and they were not discussed. Some of the clinical team told us they were not invited to meetings where significant events were discussed. The policy stated a review of the significant event should be carried out as soon as possible after the event. There was no record of any discussion for several significant events. The business manager told us they had previously told staff to document discussions, and they would issue a reminder.

The practice worked with patients and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when patients moved between different services. There were systems in place for processing information relating to new people joining the practice. The practice worked with other providers to deliver shared care when patients moved between services. Referrals and test results were managed in a timely way. However, many of the systems, such as those managing infection prevention and control, medicines management and building safety were not effective, putting people at risk.

The practice had a safeguarding policy in place, but the business manager told us this was from 2021 and was out of date. The policy did not name the safeguarding leads. The Registered Manager told us they had adopted the Integrated Care Board (ICB) safeguarding policy. That policy also did not mention that it had been adopted, did not mention Glenroyd Medical, and did not mention who the safeguarding lead was.

The Registered Manager told us they were the nominal lead for safeguarding, and that the business manager also had a lead role. Staff identified the Registered Manager as the lead. Notices displayed at the practice dated April 2025 named both GP partners as the leads.

The business manager told us it was their policy for all staff to repeat all mandatory training, including safeguarding, annually. They had last completed the training over 2 years ago. Other members of the team had last been trained over a year ago. The practice’s outdated policy stated that training would be in line with ICB policy; that policy was that training should be repeated every 3 years.

The practice maintained a list of vulnerable people.

The practice worked with people to understand and manage risks by thinking holistically. They provided 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. People were advised on risks related to their condition and actions to take if their condition deteriorated.

The practice 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 practice had a main surgery and a branch surgery. The main surgery was managed by NHS Property Services. A fire risk assessment had been carried out at the branch surgery in 2021 and had been repeated in September 2023. Actions required in 2021 had still not been completed when the 2023 risk assessment was carried out. We looked at a selection of the actions that needed to be completed within 1 to 3 months of the 2023 risk assessment. None had been completed. These included fitting various warning signs, filling in holes in doors and ceilings, fitting or replacing intumescent strips to doorframes to prevent fire and smoke from spreading, and having some electrical equipment tested. It was also noted that no checks other than weekly fire alarm checks were taking place. The business manager said they were unaware of any further checks being carried out, and no evidence was kept in the fire folder where the fire alarm checks were held. Staff told us they thought a fire evacuation had taken place last year, but no evidence of this could be found. The process for managing safety in the event of a fire was unclear. The majority of non-clinical staff were trained as fire wardens, and the business manager told us that whoever decided to put on the fluorescent jacket took charge if they needed to evacuate the building. We were concerned this could lead to a delay in the event of an emergency.

One clinician told us there was not enough equipment available for them to be able to do their job. They said they now carried some of their own equipment. There was a risk of equipment not being tested or calibrated if the practice was not aware of all equipment in use. The practice manager told us that on the day testing takes place staff are told to take all the equipment to one room. Stickers were no longer put on equipment when it was calibrated, or when portable electronic testing took place. They were provided with a list of checked equipment but could not say if everything at the practice had been checked. They were going to use the list of checked equipment as the list of what was held at the practice.

The service had blinds with looped cords and chains. They had fit cord securing clips at all windows to reduce the potential danger of strangulation, but these were not being used in all rooms.

The practice 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.

The practice provided us with their recruitment policy. This was undated. It gave information about the recruitment process and included a checklist. Not all the required checks were included in the policy. Although references were mentioned, there was no mention of the need to hold a full employment history, photographic evidence of identity, checks of membership of professional bodies and the need for Disclosure and Barring Service (DBS) checks. The policy stated it was to be followed in the recruitment of all staff.

We checked the information held for a selection of staff. The system was very disorganised. Some information was kept in physical files, some on-line, and some of the information requested was found in the email in-boxes of managers. They told us they checked professional qualifications at the interview stage but did not record this check. They also told us that professional registration was checked when a clinician was employed but the check was not repeated as it was the clinician’s responsibility to stay registered. A document showing Nursing and Midwifery Council (NMC) membership was checked annually for nurses was later found. Although the managers told us they did not keep the employment history for staff as it was not required after the interview, of those requested, a work history was found for all except 1 staff member. Some clinical staff, including GPs, had been recommended to the practice. The managers told us that they did not follow the normal recruitment procedures if staff were recommended. No references had been obtained for the clinicians we checked. Another member of the clinical team had previously been employed and rejoined the practice. The business manager told us they did not request all the required documents because they were known to the practice. This staff member was not included on the practice’s training matrix to monitor their essential training.

Training was not effectively managed. The system used by the practice did not enable managers to identify those who were not up to date with their training and therefore did not have the assurance that their staff remained skilled and competent to carry out their roles.

The practice provided us with a matrix showing what mandatory training all staff had completed. We checked a random selection of staff. The business and practice manager explained that the matrix was compiled from information provided by staff. They asked staff to give them training certificates and these were used to populate the matrix. Although they told us the system was easy to manage, our checks showed that the matrix was inaccurate; some training had been completed by staff without them informing the managers. They acknowledged that they could only effectively monitor training if all staff provided them with certificates of completion.

The practice provided us with their appraisal policy. This was undated. It stated that all staff would have an annual appraisal. The system for managing supervision and appraisal was not effective. Non-clinical staff had received an appraisal earlier in 2025, but this had been their first appraisal since the beginning of the Covid-19 pandemic. One clinical team had not had any formal appraisal or supervision since before the pandemic. Managers told us another clinical team had also had no appraisals, but we found evidence of one clinical staff member having one in 2023.

During the assessment we were told that a structured system of clinical supervision was not yet in place but would be commencing. Following the assessment, the provide sent us some evidence of clinical competency being assessed.None of the managers had had an appraisal since at least before the pandemic, with one manager telling us they could not remember ever having one. The business manager told us that if staff did not ask for an appraisal they could assume they were happy.

The practice 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 practice provided us with their infection control policy. This was undated. The policy stated infection control training would take place for all staff annually. The business manager told us staff had not been trained as they did not know this training was mandatory. When they checked their training systems, they realised 6 non-clinical staff had completed training, as had 1 member of the clinical team. They could find no evidence that the leads were trained. Not all staff were aware of who the leads were.

The policy stated that quarterly unannounced infection prevention and control inspections would be carried out, but the lead for audits told us this did not happen. Annual audits were carried out for the main and branch sites, and the last ones had been in June 2024. The checklists were for the premises as a whole, and did not cover individual rooms. These audits had not identified issues we found during our assessment. They stated that no toys were at the practices, but there were toys in the waiting room of the branch surgery. We found several boxes of surgical gloves and face masks that were past their expiry dates. We also found out of date items at the main and branch surgery, including syringes, hypodermic needles and dressings. One syringe expired in May 2023. The first aid kits at both practices had items that were past their expiry dates. The business manager ordered new ones during the assessment. They told us staff were given time for checking the expiry date of items. We found many boxes of out of date face masks and gloves in a room at the main practice. However, these were labelled as being out of date and not for use. No hand-washing audit had been carried out.

We observed that trolleys in consultation rooms were dusty. The business manager said it was the responsibility of their clinical team to clean these. The practice employed a cleaning company for the branch surgery. We saw that mops were stored head down in buckets. Although they were colour coded, we saw a yellow mop stored head down in a blue bucket. The cleaners trolley contained domestic cleaning products and equipment. A bottle of domestic bleach was stored on the top of the trolley with no top on it, so there was a risk of spillage. A bottle of clinical steriliser was also stored with no top, and this had an expiry date of 10 August 2021.

The practice did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

The practice did not have a policy or process to safely monitor blank prescriptions. At the main surgery the only serial numbers kept were for new unopened boxes. There was no record of the serial numbers of any prescriptions used in the printers. At the branch surgery there was a record of the serial numbers of the new boxes when they were delivered, but no running check of serial numbers for each printer. In addition, we found prescription pads, used to handwrite prescriptions, at both surgeries. At the main surgery we found 12 prescription pads, all with the name and surgery address of GPs on them, and 29 prescription pads with the names and surgery address of nurse independent/supplementary prescribers. At the branch surgery there was 1 pad for a GP and 6 pads for nurse independent/supplementary prescribers. The service kept no record of any of these prescription pads and did not know how long they had had them for. Therefore, it was not possible to determine if items had been misappropriated.

The practice stocked medicines that needed to be stored below 25°C. There were no thermometers in the rooms these were stored in, and no oversight or system in place to ensure these remained safe to use. We saw that one medicine in the emergency bag had expired in January 2025. The service had a new in-date one and changed this while we were there. There was monitoring of medicine fridge temperatures, but at the branch surgery we saw some gaps in monitoring and some occasions when the temperature went over the safe maximum, with no evidence of any action being taken in mitigation.

The process for authorising nurses to administer certain medicines was not effective. Of the 9 Patient Group Directions (PGDs) we checked, 8 were incorrect. Nurses had been added to them after the authorising manager had signed them.

We carried out a series of searches on the services clinical systems as part of this assessment. These searches indicated that some people prescribed Methotrexate (a medicine used to treat autoimmune conditions) did not have up to date monitoring. Although some blood tests had been carried out at the hospital there was no evidence the service had checked these prior to prescribing, and they told us it was arduous to code this check manually. A medicines safety update in 2020 advised prescribers to inform people what day Methotrexate should be taken and record this in their records. This had not occurred for any of the service users we checked. The practice told us they would like to do this, but their clinical systems would not allow it. The practice were unaware that instruction could be free typed in the patient record.

Our clinical searches found people prescribed nonsteroidal anti-inflammatory drugs (NSAIDs, used to reduce inflammation and pain) were not prescribed Protein Pump Inhibitors (PPIs) to decrease the risk of gastro-intestinal bleeding. The practice told us they prescribed enteric-coated tablets, so the risk was reduced. British National Formulary (BNF) states that enteric coating does not significantly decrease the risk of gastrointestinal bleeding, and the Medicines and Healthcare products Regulatory Agency (MHRA) guidance clarifies that enteric-coated aspirin reduces dyspepsia but not gastrointestinal bleeding. The practice told us they would review National Institute for Health and Care Excellence (NICE) recommendations against their current practice.