The Limes Medical Centre

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.

We found that although systems and processes were in place, not all aspects of these systems were safe, so there was an increased risk that people could be harmed.

We were not assured that effective systems and processes were in place for safeguarding. Further gaps were identified in infection control, safe environments, managing risk, medicines, the management of hospital letters and urgent referrals.

The provider 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.

Although we saw evidence of systems and processes to identify, record and share learning from safety events, it was not operating effectively to ensure all safety events were identified, investigated and reported. Lessons were not always learnt to continually identify and embed good practice. There was no robust system to record significant events and incidents.

The practice had an up-to-date significant event and learning events policy that encouraged staff to report all safety incidents to foster learning and help prevent recurrence. However, this policy was not being followed. For example, different staff told us they would report to their department heads, instead of adhering to policy. This led to some staff not being aware of events happening in the practice, or meetings and discussions other than those affecting their teams, or unless they were involved with them. Clinical and non-clinical events were discussed in clinical governance meeting minutes attended by the partners and at their specific learning events meeting held 3 times a year. Clinical meeting minutes provided did not show learning events as a standing agenda item. Not all practice staff attended these meetings and there was no evidence of cascading learning to staff that could not attend; however, the practice told us that not everyone could attend every meeting but each team was represented and the updates and minutes were shared with the rest of the team by email.

The provider had not always identified and taken action to help reduce the risk of the incident happening again. For example, the practice had recorded 4 patient data breach incidents in the past 12 months, 2 of which had occurred in 1 month.

Their policy only listed 3 examples of significant events in general practice, so there was a risk that staff would not be able to identify or report other safety events in the practice as reportable incidents and we saw evidence of this. For example, there were gaps in the level of understanding of what constituted a significant event and this differed within the practice, as different staff in the practice had different understandings of what constituted a significant event. For one member of staff, there was a perception that any safety incidents were negative, rather than considering them as an opportunity to learn.

Although the practice’s policy stated all significant events were to be entered into the significant event log, not all events were. Some safety incidents were recorded in accident books, available at each site, instead. This resulted in missed opportunities to prevent recurrence, learn and cascade the learning from them, such as following trips, slips, falls and manual handling injuries.

The practice told us 13 significant events had occurred in the past 12 months which we reviewed; however, we were not assured that all significant events had been identified and discussed as such. For example, we found that at least 2 significant events discussed by staff on inspection were not included in this submission and at least 6 other significant events included in their learning events meeting minutes for the past year were not included in their significant event analysis log. Staff described a patient collapse outside the premises that required a member of staff to provide resuscitation assistance, which resulted in a positive outcome for the patient due to the staff member providing lifesaving intervention.This had not been identified or analysed as a significant or learning event, despite their emergency incident policy stating clinicians should ensure they record their involvement in an external emergency accurately as this information may be required at a later date and this included positive events.

The practice also sent 2 logs of learning events that had started off as complaints; however, these logs did not provide any information as to what the incidents were. Additionally, the significant event log submitted by the practice did not include sufficient patient details, so we could not establish if all the patients on the 2 logs were included in the events log provided.

The policy also stated that ideally, medical, nursing and other staff such as reception staff should be invited to the significant event meeting as each would have a different perspective, which may help generate a variety of potential actions. At least 4 staff told us incidents and significant events were not shared with them, as well as any improvements. Some staff told us they were not invited to meetings where significant events and incidents were discussed and this resulted in knowledge gaps; for example, some staff described events that had occurred years prior but were not aware of recent examples of the same incidents that also recurred in the past year.

The practice worked with a range of healthcare services to establish and maintain safe, effective systems of care for patients. Clinicians mostly followed established care pathways for diagnosis, treatment, and referral to specialist services. They made sure there was continuity of care, including when people, including those in all 8 of their care homes moved between different services. However, improvement was required to ensure their systems for incoming correspondence was effective and consistently applied by all staff.

Test results were managed in a timely way and we saw evidence of effective oversight. For example, on inspection, we saw there were 33 unactioned abnormal blood tests dated 2 days before inspection, which is a small number for a practice of this size, indicating an effective system in place to ensure test results were managed in a timely way.

The practice told us they recently implemented various changes within the administration team to improve the quality of workflow and processes. For example, they introduced a quick access, referral portal toolbar system that consolidated links to various referral portals into a single location, which would also ensure proper coding of portal referrals and an audit of this system confirmed this.

Whilst we saw a system to manage all daily incoming correspondence, they were not always actioned by the relevant staff in a timely manner; for example, on inspection we saw 126 various documents such as discharge letters and blood pressure readings waiting for relevant staff to action dating back to March 2025, 3 months before the inspection. This was consistent with patient feedback where some patients told us that emails and follow up letters that they sent to the practice had not been followed up and they also raised concerns that some staff would not pass on their emails to the GP to be reviewed. While this presented a potential risk where clinical information such as home blood pressure readings required timely action, these instances were few in number relative to the overall patient list. Feedback and our wider review indicated that this was not reflective of the practice’s usual performance, where most correspondence was handled appropriately and in line with expected standards.

The practice had an effective system in place for the management of 2-week wait referrals along with a safety-netting policy for urgent referrals.

Whilst we received positive patient feedback regarding how their referrals were managed, including from the care homes, we also reviewed patient concerns regarding this. For example, we reviewed a patient complaint regarding a GP handwritten referral letter rejected by external services but did not find evidence of what action the practice took to ensure referrals sent to other services were appropriate and in line with practice guidelines. This placed the patient at risk of delayed diagnosis and treatment. One care home also described a confusing registration process and a system that had changed but not communicated with the home. However, the practice told us there was no change in registration processes.

We were not assured of effective systems and processes were in place for safeguarding and that relevant safeguarding information was always shared with the relevant staff, quickly and appropriately. Safeguarding policies for adults and children were in place and known to staff. Staff training records showed 3 members of staff were overdue with their safeguarding training. Most staff demonstrated a clear understanding of safeguarding and were able to explain previous incidents and the process for escalating concerns to the safeguarding leads. However, some staff could not describe specific indicators of potential safeguarding issues, which may limit early identification of risk.

The practice maintained registers of vulnerable people. There was a process to follow up children who did not attend appointments and they acted on concerns working in partnership with other organisations. However, some of the registers did not include sufficient information to show why patients were on that list and when they were reviewed; for example, the child protection registers only provided details of the number and age of the patients and no other information.

Minutes were shared with relevant staff, including those who did not attend the multi-disciplinary team meetings and the monthly safeguarding meetings. However, no audit trail was maintained to confirm who had read them. The lack of an audit trail for multi-disciplinary team meetings and safeguarding meetings presents risks, as there is no assurance that staff have reviewed or acted on critical information, increasing the likelihood of missed or delayed actions.

Vulnerable patients were also discussed in their monthly GP and practice manager meetings but not with the wider staff. Management staff told us that any safeguarding information was filtered down to staff on a need-to-know basis and this was consistent with some staff feedback, whereby those who reported safeguarding concerns to a GP did not always hear back regarding the outcome. The practice told us key issues or concerns would be raised with wider staff teams where necessary.

Job applicants at the practice were required to undergo either an enhanced or standard DBS check depending on the position applied for. The practice told us all the relevant staff received Disclosure and Barring Service (DBS) checks; however, we did not find clear systems in place for this, as the list provided was not up to date, so there was a lack of clarity as to which staff had their DBS checks and some clinicians were not on this list. We discussed our findings with the practice following the inspection and they told us that all staff had received the appropriate DBS checks and none were outstanding. However, we were not assured that the system to log and monitor current staff DBS checks operated effectively.

There was a chaperone system in place and training records showed all staff had received chaperone training.Each branch surgery displayed chaperone posters, including digital posters.

We looked at how the practice managed risk within the service and whilst we found adequate systems and processes in some areas, there were significant gaps in systems and processes in other areas. Staff could recognise a deteriorating patient and knew of action to take; for example, sepsis red-flag symptoms and the escalation process. Evidence from recent positive patient feedback showed how staff had acted without delay when a patient was suspected of experiencing sepsis. We saw several cases where patients received same day, urgent care from the practice after presenting with red-flag symptoms; for example, clinicians were effective in spotting suspected appendicitis which led to the patient receiving immediate hospital treatment.

People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms and patient feedback we saw confirmed this.

Although the practice held appropriate emergency medicines at all 4 sites, adrenaline was not stored in the clinical rooms where vaccines were administered. This left patients at risk of delayed treatment in the event of an emergency.

There was a lack of governance and oversight of checks of the emergency medicines and equipment at all 4 sites, particularly for the 3 branch sites. Staff told us they carried out monthly documented checks of all emergency equipment, in line with their policy.

We found several adult and paediatric face masks and nebuliser masks had expired since 2020 and 2021, meaning the checks completed by the practice had not been effective or acted on to make sure all equipment was available and suitable and safe to use.

There was oxygen and a defibrillator at all the sites. However, the oxygen cylinder at the site in Theydon Bois was less than half full although there was a full cylinder next to it. The defibrillator batteries at 2 of the sites were half or less than half charged. Inadequate oxygen supply and partially charged defibrillator batteries could delay or compromise emergency response, increasing the risk of harm to patients in the event of a cardiac or respiratory emergency. Following the inspection, the practice told us that thedefibrillator was not rechargeable and relied on disposable batteries, with automatic prompts indicating when replacement was required.A centrally held spare battery was available, the process followed manufacturer guidance and the defibrillator was safe and fully functional at the time.

Supplementary equipment such as a razor and absorbent towel was not available at any of the branch surgeries. There was no defibrillator signage displayed in the practice locations, to direct people to their location. There was a risk of delay to providing emergency care without this supplementary equipment.

The practice provided records to show the defibrillator for all the locations were inspected by an external contractor in February 2025 and calibrated by an external contractor in March 2025. After calibration testing of the defibrillator, the practice was provided with a series of recommendations including 6-monthly date checks on the pads and batteries. However, there was no evidence to show if all the recommendations were put in place.

When we looked at the various consumables at all the branch sites, we found several had expired varying from swabs that had expired 6 months prior, dressings, urinalysis sticks, needles and glucose meter sticks with expiry dates ranging from 2017 to 2020. The practice had not been aware of this. We discussed our findings with the practice who acknowledged our findings. Following the inspection, the practice told us that the nursing team had reviewed their policy on stock control and all sites had been visited to check there was no out of date stock.

The practice did not maintain effective oversight and did not always control potential risks in the care environment, as we found significant gaps that placed people using the premises at risk of harm if action was not taken to address the defective areas.

There was a facilities lead and contracts were in place to ensure the premises were maintained at all 4 locations. They told us all environmental safety documentation was kept at their main Epping site. There were adequate security arrangements at all the 4 locations and security CCTV covered all external areas, with signage in place.

When we reviewed fire safety at the main Epping site, we found there was a fire safety policy and appropriate, documented evacuation procedures. There were designated fire marshals who had received the appropriate training and fire drills took place twice a year at all 4 locations, which was due as last carried out in December 2024. Their firefighting equipment was in date at all 4 locations. However, training records showed gaps in fire safety training, as 3 clinical and non-clinical staff were overdue their annual fire safety training; however, the practice demonstrated that only 1 staff member was overdue this training due to long-term absence and the other 2 staff member's training was up to date.

The fire risk assessment for the main Epping site was carried out in June 2025 and fire risk assessments for the sites at North Weald and Theydon Bois in July 2024. The practice had acted on some of the recommendations from them. However, the practice had not acted on other recommendations, such as relating to fire doors not fully closing on release, which were highlighted in both the 2024 and 2025 fire risk assessments, removing items such as cleaning equipment, that were being stored in electrical cupboards at 3 of the 4 sites and removing chairs from the heaters at the branch in Theydon Bois, as this was observed on inspection. We also found the concerns around the electrical cupboard being used for storage was raised in several of the risk assessments; however, this had not been acted on and was a recurring theme in 3 of the branch locations. There was a risk to people’s safety due to combustible materials being stored in an electrical cupboard.

Fire safety at the Waltham Abbey site was generally well managed, with clear evacuation procedures in place. NHS Property Services (NHSP) maintained fire safety equipment and scheduled twice-yearly fire drills, which were due at the time of inspection. The practice provided fire risk assessments dated April 2024 and June 2025, and actions from the 2024 assessment had been completed. The premises were rated as medium to moderate fire risk and we observed clear fire exit signage throughout the building. There were no designated fire wardens at branch surgeries, as staff worked across multiple sites.

When we looked at Portable Appliance testing (PAT) and equipment calibration, we found them in date and carried out at all the 4 sites in March 2025. Most of the equipment at the 4 sites passed the testing; however, several pieces of equipment such as the pulse oximeter and thermometer had expired in April 2025 and a wall mounted height measure had failed the calibration test at the main site, including other equipment at one of the branch locations. Following the inspection, the practice told us these pieces of equipment were removed and replaced.

When we looked at the fixed electrical installation testing, we saw findings were satisfactory for 2 of the locations. The fixed electrical installation testing at the Waltham Abbey site was carried out by NHSP and was rated as unsatisfactory due to a significant number of potentially hazardous defects. Further investigation was undertaken to assess these issues. Evidence provided by the practice confirmed that all urgent defects had been rectified; however, additional action was required to complete the recommended improvements and address residual risks identified during the assessment. Following the inspection, the practice provided evidence of completed works in January 2026.

The fixed electrical testing at the North Weald branch was deemed unsatisfactory due to numerous potentially dangerous issues. Further investigation was required, as several findings demanded urgent action. Key concerns included the absence of surge protection and incorrect labelling of accessories. The testing identified 52 defects, which the practice reported as rectified. Evidence provided indicated that remedial works had been carried out and we saw evidence of this.

Two fixed electrical installation testing records were provided for the Theydon Bois location, dated July 2022 and June 2024, even though such tests typically cover a five-year period. The July 2022 record was rated as unsatisfactory due to identified areas requiring improvement. However, the June 2024 record does not clearly indicate whether these issues were addressed. Confirmation of completed works was received in January 2026.

Up to date gas safety records were maintained for 2 of the locations where they were required.

We found gaps in the management of legionella. The practice carried out water hygiene maintenance service of the cold-water storage tanks in November 2024 and maintained water testing logbooks. They told us legionella inspections had been carried out for all the 4 sites by an external contractor, so they were in date and had passed the assessment; however, we were not shown evidence of these specific risk assessments that identified potential hazards in order to verify this. They provided us with a combined, general inhouse legionella risk assessment for the 3 sites excluding the location managed by NHSP; however, the assessment was next due in May 2026. We were not assured all relevant areas had been covered due to the comprehensive nature of such assessments.

When we reviewed the legionella logbooks, there were gaps in recording the dates when water temperature checks were carried out. We found this was the case for 3 of the locations and we also found for one location; there were no readings documented between July and September 2023. Despite the practice sending us readings for this period after the inspection, we were not assured of their accuracy or where the figures came from, due to the length of time since they were meant to be recorded. The practice told us they had commenced readings in a new logbook due to a change in personnel; however, under the control of substances hazardous to health (COSHH) regulation,the assessment must be reviewed if the change of staff affects competence or the validity of existing control measures.We also found there were water temperature breaches; for example, 30.1 degrees Celsius for hot water. There was a risk of contracting legionella disease if temperature control was outside the recommended levels.

When we reviewed the environmental safety arrangements at their branch locations, we observed appropriately furnished waiting rooms and clear walkways. One of the branch locations had a lift which was serviced and in good condition and there were no concerns with external premises and surrounding areas. An asbestos survey was completed at the main Epping site on 6th December 2019 that established that there was no asbestos present.

When we reviewed the health and safety arrangements, we saw there was a health and safety policy in place. The practice told us staff had access to an extensive health and safety handbook; however, we did not see refresher health and safety training records for staff, except for those related to manual handling. Therefore, we were not assured that health and safety was being managed effectively in the practice. We saw some significant health and safety related incidents, including recurring incidents, such as trips, falls and manual handling injuries that resulted in, or could have resulted in serious injury to people recorded in the accident book.

The practice conducted an in-house general risk assessment and an annual health and safety review across all 3 branch locations. However, these assessments did not provide sufficient assurance that all risks were identified or that the likelihood and severity of harm were adequately evaluated, along with the necessary actions. For instance, the absence of a disabled pull cord in a patient toilet at one branch was not identified in either assessment.One branch location did not have an emergency pull cord in its standard toilet, which is not a mandatory requirement outside a designated disabled facility. However, the practice must ensure that a risk assessment is undertaken to identify any potential risks to disabled patients using the standard toilet and establish how they would request assistance in an emergency.Additionally, health and safety posters at several locations were incomplete, lacking the names of designated officers.

There was a COSHH policy and general risk assessments in place for all the 4 locations.

Safe recruitment practices were followed, although there were issues with DBS monitoring records for staff. The service made sure there were enough qualified, skilled and experienced staff. They worked together well to provide safe care that met people’s individual needs.

There was a rota system and staff felt there were enough staff, although some parts of the administration team with smaller numbers of staff felt cover could be difficult at times; however, other teams were always willing to step in and help when needed. There were systems in place for sickness and busy periods; for example, the practice had a dedicated absence reporting line and workload was safely adjusted and distributed prior the opening the practice. Additional staff, including locums were brought in where required and reception staff had the option for overtime.

The development needs of staff were managed appropriately and staff felt there was a real focus on professional development and we saw evidence of this. For example, the provider supported staff to become accredited in undertaking spirometry testing and one of the GPs was supported to complete their educational supervisor training for GP registrars. We also saw their advanced nursing staff receive dermoscopy training to look at moles under microscope to recognise signs of benign or cancerous moles.

However, we identified some gaps in relation to appraisals and training. We saw staff had the opportunity to provide their feedback and where concerns were raised during the appraisals, we saw the provider took steps to alleviate the staff member’s concerns and resolve their concerns. However, there were gaps in appraisal systems as some staff were overdue their appraisals since 2022 and 2023. Following the inspection, the provider sent updated appraisals information, including a documented system to monitor this.

Most of the training was up to date, although there were gaps in mandatory training including, the disability and autism training, sepsis and fire safety training for some of the non-clinical staff. The practice told us that disability and autism training was currently in progress for staff at the time of inspection. Training records did not show all the mandatory training records for 5 of their sessional GPs. There were no health and safety training records seen for all practice staff and this information was not included in their mandatory training record. The practice told us this was covered as part of their induction as well as under their manual handling training; however, we were not assured that other aspects of health and safety training outside of manual handling was carried out and this posed a risk to people as there were health and safety related accidents in the practice.

The practice told us systems and processes were in place to undertake staff annual appraisals and we saw that leads from the different staff groups carried out their own team appraisals. We sampled 6 completed appraisals and 5 completed clinical supervision records and found they were well documented.

Appraisals for the clinical pharmacists were conducted by their agency provider, with input from all 6 practices who were part of the Primary Care Network (PCN). This was reported back to the lead GP of each practice with any issues, concerns or competency gaps. However, from the records provided we saw there were gaps in this system as 11 staff were overdue appraisals, 6 of which were from the nursing team and at least who had last received their appraisals in 2023. Some of the appraisal records showed staff feedback was not always documented where improvement was required. This was consistent with their 2024 staff wellbeing survey carried out showing 31 out of 43 staff responded yes to having received their annual appraisals. We discussed the gaps with the practice who told us going forward, they would hold monthly appraisal meetings to review appraisal dates and book times one month prior to expiry. There was an induction policy and we saw completed induction records for new staff; however, effective oversight was required to ensure new starters understood the systems and processes within the practice following their induction period, as we found gaps in knowledge.

Staff were working within their agreed areas of competence; however, further oversight was required to ensure those undertaking specialised tasks such as infection control audits and wound care activities had the training, competencies and supervision to do so.

Our records showed 2 nursing staff carried out contraceptive reviews. Both of these nurses were appropriately trained to undertake these reviews.

Although there were infection control systems in place, we found gaps in some of these systems.

Staff immunisations were in place for those that required them.

Clinical rooms at the main Epping site were carpeted and a risk assessment was completed by the infection control lead and carpets were deep cleaned every six months. The lead also assessed the lack of sluice facilities across all four sites and confirmed reliance on single-use disposable equipment.

The environment at all 4 locations was clean and cleaning schedules were in place for equipment and site wide cleaners looked after their Waltham Abbey location. We saw appropriate clinical waste disposal systems in place and a clinical waste audit was carried out on each site.

The practice had an infection control policy and a designated infection control lead. However, we were not assured the policy in place was appropriate as it had not been produced by the practice and it had not been assessed to ensure the policy was appropriate and practice specific.

Although most of the staff had received the relevant infection control training, we found gaps in training records. For example, 3 clinical and non-clinical staff were overdue their 2-yearly training. The practice told us infection control updates took place during their Time to Learn days or evenings which was last held in June 2025 and well attended by staff face to face or virtually.If staff could not attend the Time to Learn days, which included infection prevention and control training, face to face orvirtually thepractice told us the presentation was emailed out to them for their review.

When we looked at infection control audits, we were not assured staff undertaking this task were adequately trained and supervised to do so. We were told the infection control lead carried out the infection control audits; however, we found a non-registered clinical support staff was undertaking the infection control audits, instead of the infection control lead. The practice provided evidence of appropriate infection prevention and control training for this staff member, however we found some gaps in knowledge; for example, reference was made to a defunct commissioning body when assessing clinical waste and to a planned renovation in 2018. We also found non-compliant plug-in basins at the branch locations were not documented within these audits.

The checklist for the main site also documented that the outdoor clinical waste bin was secured to the premises which was not the case when we visited the premises. When we spoke to the provider, they explained the difficulties securing this bin when it came to emptying into the bin lorry; however, a risk assessment had not been completed to reduce the risk of the bin being wheeled away. This was particularly relevant as there had been a previous incident at one of the branch locations where the domestic waste bin was stolen.

During our review, we observed that none of the branch locations displayed safety posters related to sharps and needlestick injuries. Handwashing posters were present in clinical rooms.

The practice also recognised one of their branch locations where they had ongoing infection control concerns where the site wide cleaners were not emptying their bins. They stated they had frequent dialogue with the cleaners; however, it was not clear what action was taken to rectify these concerns. Their Waltham Abbey location had a cleaning audit carried out by NHS Property Services in April 2025 and results showed 269 elements were audited, 255 passed and 14 areas failed the audit. However, there was no evidence provided to show what action was taken to rectify the identified areas. This branch location was owned by NHS Property Services and we saw evidence the practice had raised concerns relating to the cleaners with them and were waiting for them to take action.

Although the practice had policies and systems intended to ensure the safe and appropriate use of medicines, these were not consistently implemented or monitored. We found significant gaps in key areas, including cold chain management, controlled drug checks, safety alerts and prescription security. For example, vaccine fridge temperatures were not monitored in line with national guidance, leading to breaches in the cold chain that could compromise vaccine efficacy. Controlled drug checks were not always signed by two identifiable staff members and prescription stationery was not securely stored or logged at all branch sites, creating a risk of misuse. These weaknesses in oversight and compliance placed patients at risk of harm and indicated that governance arrangements for medicines optimisation were not comprehensive.

Staff had the appropriate authorisations to administer medicines, including Patient Group Directions or Patient Specific Directions.The prescribing team included 3 clinical pharmacists, 4 primary care network (PCN) pharmacists and 1 pharmacy technician. We saw evidence from 3 clinical pharmacist meeting minutes where prescribing was discussed, including learning events and action items. Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics and prescribing data reviewed as part of our assessment confirmed this. For example, the number of antimicrobials and multiple psychotropics issued by the practice were lower than local and national averages. The practice was also within the expected range for the prescribing of opioid and non-opioid analgesics, especially Gabapentin and Pregabalin, which can lead to dependency and serious harm. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.

Our clinical searches identified 24 out of 246 patients prescribed gabapentinoids had not received a medicines review in last 12 months. We reviewed 5 of these records and found 3 patients were overdue a review. These were addictive medicines which required timely reviews to ensure compliance, avoid overuse and monitor side effects.

We also sought feedback from the 8 care homes looked after by the practice regarding their medicines management and the feedback was generally positive. They told us the practice had an effective medicines ordering process and the system mainly worked well. Some of the care homes; for example, the home for residents living with the long-term effects of an acquired brain injury told us the practice clinical pharmacists completed regular medicines reviews for their patients which included 3-6 monthly reviews or annually depending on need. This also included high risk medicines such as warfarin. Care home staff told us the practice were responsive to requests during their changeover period. However, some people told us that medicines reviews were conducted by phone, which they felt was not ideal, as they preferred face-to-face consultations for discussing their medicines in more detail. They also reported that reviews only occurred when they specifically requested them, rather than being routinely scheduled by the practice. They also told us the practice could work on updating the prescriptions once those have been reviewed and amended, as they had to email and chase to get a new prescription.

We saw good practice in relation to the prescribing of high-risk medicines. For example, when we carried out our clinical records review for the management of Disease Modifying Antirheumatic Drugs (DMARDs) such as Azathioprine, we found 18 patients were prescribed this medicine and all 18 patients had received the required monitoring in the last 6 months, as per recommended guidelines.

However, we also found some gaps in some aspects of their medicines management. For example, we identified 1,501 patients who had received a medicines review in the past 3 months and when we reviewed 5 of these records, we found 2 reviews that did not have a context documented to their review;however, this was an area of low risk and we were overall satisfied with the management of medicines reviews.

Our clinical searches also identified 223 of 2,146 patients prescribed Ace inhibitors to treat heart failure and high blood pressure, had potentially not received the required monitoring. A review of 5 clinical records showed monitoring was overdue for 4 of these patients and they were at risk of unnoticed kidney damage.

The practice had systems to manage and respond to safety alerts and medicine recalls, led by the clinical pharmacy team who reviewed and circulated Medicines and Healthcare products Regulatory Agency (MHRA) notifications. We saw evidence of 2-cycle medicines audits and audits based on the patient safety alerts. We saw examples of how they responded to an MHRA alert regarding patients prescribed aldosterone antagonist and ACEI/ARB medicines. Our clinical searches identified 22 out of 109 patients affected by the alert. We reviewed 5 of these patient records and found 1 patient was overdue monitoring. There was a risk of undetected salt abnormalities that could make the patient unwell.

Following our clinical searches, the practice promptly acted on our findings and held a clinical team meeting with most of their staff and submitted an action plan. They provided evidence to show discussions around medicines reviews and how to conduct them comprehensively. Systems were also put in place for patients not engaging with monitoring and this included short scripting their medicines.

When we looked at their arrangements for cold chain monitoring, we were not assured staff had received the necessary training, as we found national guidelines were not being followed, leading to inadequate monitoring and breaches in the cold chain. Effective arrangements were in place for the main site; however, there was no adequate monitoring of the vaccines fridge temperatures at all 3 branch locations.

There were significant gaps in manual fridge temperature checks; however, the practice told us the nurses checked the data logger on each day they manually checked the fridge temperatures but this was against national guidelines that recommended the vaccine fridge temperatures to be checked twice a day. For example, one of their branch locations showed the fridge temperatures were only checked 5 times in March 2025 and twice in April 2025.

We reviewed their data logger entries for most of June 2025 for one of their branch locations as well as graph data from November 2024 to May 2025 and not only found periods where the fridge temperatures spiked to over the recommended maximum temperatures of 8 degrees Celsius but the data logger appeared to show temperatures of 9.5 degrees Celsius had been reached for most of June 2025, breaching the cold chain. However, there was no evidence to show what action was taken in response to this, such as completing a significant event, contacting patients and the local Integrated Care Board (ICB) or NHS England. There was a risk that inadequate cold chain monitoring would lead to a breach in vaccine efficacy and patients receiving potentially ineffective vaccines.

Although the practice stored Morphine, a controlled drug used for pain relief, securely at each site, checks were not carried out in line with national guidance, for example signed by 2 members of easily identifiable staff and the stock level recorded. Their medicines management policy did not provide information regarding how they could access their Controlled Drugs Accountable Officer (CDAO).

Prescription safety was not managed appropriately and securely at all 4 sites. Although there was a prescription safety policy in place, it did not include a clearly documented system to effectively monitor logging and storing of blank prescriptions at the other 3 locations. The record keeping for blank prescriptions was also unclear and incomplete. We observed the blank prescriptions were not stored securely in the branch locations. The practice could not assure themselves of the safe transport of blank prescriptions to the branch sites without an adequate monitoring system in place; therefore, there was a risk of misuse of blank prescriptions due to inadequate monitoring systems.

We received feedback from two patients who reported that their prescriptions were not processed in time for their planned travel abroad. Despite emailing the practice, they were left without essential medication, which resulted in flare-ups of their medical conditions.