The Longcroft Clinic

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

This is the first assessment for this provider under our new ways of reporting. This key question has been rated good.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. Representatives from the patient participation group (PPG) felt the provider took concerns seriously and proactively made improvements to the service.

The provider had processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints, and significant events, however this was not robust.

We could not be assured that staff had the time required for safeguard training, and that staff were trained to appropriate levels for their role.

Patients with long term conditions had effective annual reviews. There were systems and processes to ensure the premises were safe for use. Fridge temperatures were monitored, and emergency medicines and equipment were suitable and easy to access. However, we noted that signage to display where the oxygen was stored was incorrect. The tracking of blank prescription paper was in place however handwritten prescription paper was not securely stored. Recruitment checks were being carried out in accordance with the regulations and staff vaccinations were maintained in line with current UK Health Security Agency (UKHSA) guidance.

This service scored 66 (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 had a significant events policy and a reporting form which was accessible to all staff members. The practice discussed events and incidents during team meetings. However, the minutes to meetings did not always adequately record discussions had or the learning outcomes. We could not be confident that the process for shared learning was adequate. We noted a lack of detail in the significant events summary 2024-2025 document. This included not recording dates, no information relating to the incident and limited information in relation to the outcome for shared learning.

There was a system to record and investigate complaints. However, we could not be assured that the process for shared learning was adequate. We reviewed the complaints summary document for 2024 and noted that all 34 entries held no information in relation to what the complaint was regarding. We reviewed 3 recent complaints. We found the practice responded to people’s complaints in a timely manner and offered apologies to people. However, files did not always contain all of the information. For example, one of the partners explained that they had called the patient and discussed the complaint with them. This was not recorded in the complaint file or in the summary for shared learning.

We noted that in some of the minutes to meetings held for the nursing team, clinical meetings and partner meeting there was no recorded information regarding complaints, or significant events which may have been discussed.

We reviewed the minutes of the Complaints Meeting Summary dated 13 May 2025. We noted a complaint discussed during the meeting that we could not find listed on the central recording of complaints 2025 complaints. We also noted a complaint discussed in the May Summary but was dated as June 2025 in the central recording of complaints 2025. We could not be assured that the process for recording and reviewing complaints was robust.

Representatives from the patient participation group (PPG) felt the provider took concerns seriously and made improvements to the service. We were told that there were quarterly meetings with some of the GP partners and practice manager. The PPG gave us recent examples of where the leaders had listened to patients and the PPG. This included the recent refurbishment of the surgery and car park. As well as an audit of the new telephone system which resulted in better communication with patients to reduce missed appointments.

The service worked with people 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 people moved between different services. There were systems in place for processing information relating to new patients.

Referrals and test results were managed in a timely way. Staff involved with referrals were able to explain the processes which ensured continuity of care for patients. The service worked with other providers to deliver shared care and when patients moved between services. Staff told us there were regular multidisciplinary team meetings where patients who may be vulnerable or those receiving end of life care were discussed and actions agreed and put in place

We could not be assured that staff had the time required for safeguard training, and that staff were trained to appropriate levels for their role. We reviewed the mandatory training matrix. We noted that 50% of staff completed their training within the two-week notice period provided by the CQC before the inspection. Additionally, 6 non-clinical staff members completed safeguarding training alongside 7 to 13 other modules in a single day. We were unable to ascertain that safeguarding training was given appropriate importance and time.

Intercollegiate Guidance (which outlines the roles, responsibilities, and competencies for healthcare professionals in safeguarding children and adults) recommends Level 2 training for all staff in both adult and child safeguarding. However, the practice's mandatory training policy stated that only "appropriate" administrative and clinical staff needed Level 2/3 child safeguarding training but failed to define "appropriate" administrative staff. We saw there were gaps in completed training: only 3 non-clinical staff had completed Level 3 child safeguarding, and none had completed Level 2. While Level 1 child safeguarding training was not included in the policy, all staff had completed it. For adult safeguarding, the policy mandated Level 2 training for all staff. However, the matrix showed only 3 non-clinical staff had completed Level 2. Similar to child safeguarding, Level 1 adult safeguarding training was not in the policy but had been completed by all staff. This indicated inconsistencies between guidance, policy, and actual training completion.

The service 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.

The practice held appropriate emergency equipment and medicines which was regularly reviewed and maintained. A system had been implemented to ensure all staff knew their role within a medical emergency to ensure it was managed effectively. Staff could recognise a deteriorating patient and knew of actions to take. The practice had a duty doctor each day to support with any patients who needed urgent action. Staff had been trained to recognise symptoms which may need urgent medical attention. Patients were advised on risks related to their condition and actions to take if their condition deteriorated. We saw safety netting information clearly documented within patient records.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Health and safety risk assessments and audits had been undertaken and risks identified had been addressed. The premises were clean and contained the appropriate facilities to support infection prevention and control. There was adequate signage and clear fire escape routes. There was evidence of up-to-date medical equipment calibration and portable appliance testing (PAT) certificates were in place.

There was a business continuity plan in place, however, we noted that it contained limited information on mitigating actions for risks identified. For example, actions required for loss of power from the national grid only highlighted suggested actions the provider should take i.e. consider use of generators / register with the electricity supplier as a priority user. The continuity plan did not record if the provider had a generator to use or where one could be supplied from or if they had registered as a priority user and with who and numbers to call if required.

We noted that signage to display where the oxygen was stored was not near the oxygen cylinder. Incorrect signage presents significant safety hazards, particularly in the event of a fire.

The practice had a significant events policy and a reporting form which was accessible to all staff members. The practice discussed events and incidents during team meetings. However, the minutes to meetings did not always adequately record discussions had or the learning outcomes. We could not be confident that the process for shared learning was adequate. We noted a lack of detail in the significant events summary 2024-2025 document. This included not recording dates, no information relating to the incident and limited information in relation to the outcome for shared learning.

There was a system to record and investigate complaints. However, we could not be assured that the process for shared learning was adequate. We reviewed the complaints summary document for 2024 and noted that all 34 entries held no information in relation to what the complaint was regarding. We reviewed 3 recent complaints. We found the practice responded to people’s complaints in a timely manner and offered apologies to people. However, files did not always contain all of the information. For example, one of the partners explained that they had called the patient and discussed the complaint with them. This was not recorded in the complaint file or in the summary for shared learning.

We noted that in some of the minutes to meetings held for the nursing team, clinical meetings and partner meeting there was no recorded information regarding complaints, or significant events which may have been discussed.

We reviewed the minutes of the Complaints Meeting Summary dated 13 May 2025. We noted a complaint discussed during the meeting that we could not find listed on the central recording of complaints 2025 complaints. We also noted a complaint discussed in the May Summary but was dated as June 2025 in the central recording of complaints 2025. We could not be assured that the process for recording and reviewing complaints was robust.

Representatives from the patient participation group (PPG) felt the provider took concerns seriously and made improvements to the service. We were told that there were quarterly meetings with some of the GP partners and practice manager. The PPG gave us recent examples of where the leaders had listened to patients and the PPG. This included the recent refurbishment of the surgery and car park. As well as an audit of the new telephone system which resulted in better communication with patients to reduce missed appointments.

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.

The practice had a designated infection prevention and control lead. We saw posters around the practice including information about managing sharps injuries, handwashing, and clinical waste to support good practice. Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks.

The service made sure that medicines and treatments were safe and met people’s needs, including where people needed support due to their capacities, and preferences. They involved people in planning, including when changes happened.

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. Staff followed protocols to ensure they prescribed all medicines safely, and ensured people received all recommended medicines reviews and monitoring. Medicines were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines, and vaccines. The provider had effective systems to manage and respond to safety alerts and medicine recalls. Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring. Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.

The tracking and monitoring of blank prescription paper was in place; however, handwritten prescription paper was not securely stored.