Stephenson Park Health Group

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 good.

This service scored 69 (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 had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. Managers encouraged staff to raise concerns when things went wrong. During staff meetings, the whole team discussed and learnt from clinical issues. Staff felt there was an open culture, and that safety was a top priority. The provider had processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Learning from incidents and complaints resulted in changes that improved care for others.

For example, following a data handling error during a record request, the incident was reviewed and discussed. The service strengthened its processes by introducing a stricter Subject Access Request (SAR) procedure and improving document layout, reducing the risk of similar errors.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They ensured continuity of care, including when people moved between different services.

There were systems in place for processing information relating to new patients. The service worked with other providers to deliver shared care and when patients moved between services. Referrals and test results were managed in a timely way.

For example, the service used shared care records (secure patient records shared between services) to support safe care and continuity. In 1 case, a patient who was reluctant to engage with services was supported through coordinated working with community services. Access to up-to-date information enabled a better understanding of the patient’s needs and informed a joint approach, including reintroducing GP involvement alongside a trusted professional to improve engagement and support safe care.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Safeguarding policies were in place, accessible to staff and reflected current safeguarding leads across all sites, addressing discrepancies identified at the previous assessment. The practice maintained a register of vulnerable patients and worked in partnership with other organisations to respond to concerns.

Most staff were appropriately trained to the required level for their role. However, not all care navigators had completed Level 2 safeguarding training, which was required following a recent change in job role from administrative staff to care navigators. Leaders told us they recognised this gap and had updated its training requirements framework to ensure staff were enrolled on safeguarding training at an appropriate level for their role. Staff were in the process of completing the required training to ensure compliance with safeguarding requirements.

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 maintained effective systems to identify and respond to risk. A daily triage system was in place, with a dedicated duty doctor and clinician responsible for managing urgent patient needs during surgery hours. This supported timely assessment and appropriate clinical decision making.

Emergency equipment was available and maintained. Staff could recognise a deteriorating patient and knew of action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated. Staff received annual training in cardiopulmonary resuscitation (CPR) and the management of anaphylaxis.

The service generally managed risks within the care environment; however, improvements were needed to ensure risks were consistently identified, monitored and reviewed.

Ipratropium, used in respiratory emergencies such as asthma, was not available within the emergency trolley in line with recently updated guidance. The practice confirmed it would address this by either stocking the medicine or updating its risk assessment for non-stocked medicines. However, the existing risk assessment had not been reviewed since 2019. Leaders confirmed this would be reviewed and updated to ensure it reflected current guidance and best practice.

The premises were maintained by NHS Property Services, including statutory safety checks. While these had been completed, oversight of certification within the practice was limited at the time of the visit, and records were not readily accessible. The manager confirmed they would implement a system to maintain their own oversight of safety documentation, including retaining copies and monitoring renewal dates, to provide assurance that required checks were in place.

Since the previous inspection, appropriate action had been taken to address the absence of an emergency pull cord in the disabled toilet at the Forest Hall site. This has now been installed, improving patient safety.

During the inspection, the fire alarm was activated unexpectedly. We observed that staff responded appropriately, following the evacuation procedure, and assembling at the designated meeting point at the end of the car park. This demonstrated staff awareness and preparedness in the event of an emergency.

The external clinical waste bin lock was broken; however, the area was secured by a locked side gate, reducing immediate risk. The practice confirmed a replacement had been requested.

Contracts were in place to ensure the premises were maintained. Health and safety risk assessments and audits had been undertaken, and identified risks had been addressed. There was a business continuity plan in place which was monitored and reviewed.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Improvements had been made since the previous inspection. Appraisal processes had been strengthened, with regular appraisals now undertaken and planned annually. Arrangements for non-medical prescribers had also improved, with the introduction of a formalised approach including 6‑monthly documented audits to support oversight of competency and prescribing practice. We reviewed a sample of appraisals and formal competency records for non-medical prescribers and found these provided effective oversight of staff performance, development needs and clinical practice.

There was a range of clinical and non-clinical roles within the practice. Training was up to date, learning needs were appropriately managed, and staff were working within their agreed scope of practice. Safe recruitment processes were in place.

Some staff raised concerns regarding the planned absence of pharmacists from June 2026 and the potential impact on workload. Leaders were aware of this and confirmed that additional GP recruitment was underway to support capacity. A staff meeting was planned to communicate changes and provide assurance.

The service had systems in place to manage infection prevention and control (IPC); however, these were not always fully embedded or consistently applied.

There was limited evidence that IPC responsibilities and key requirements, such as arrangements for isolation in the event of an outbreak and escalation of IPC risks, had been fully embedded within practice processes. In addition, actions identified through IPC audits were not consistently followed up or reviewed at leadership level, as demonstrated by environmental issues. This included damaged flooring, which had not been addressed in a timely manner, although the practice confirmed this had now been escalated and remedial work was underway.

There was also no clear assurance that staff immunisation status had been reviewed against current guidance. Inconsistencies were identified between policy requirements and training intervals, specifically, the IPC policy specified a 2-yearly training requirement, whereas training records indicated a 3-yearly interval. Furthermore, key elements of IPC governance, including structured audit processes and outbreak management arrangements, were not clearly defined within the documentation.

Since the previous inspection, some progress had been made. Following recent IPC training delivered by the Integrated Care Board (ICB), there was improved awareness of IPC responsibilities, and external support had been accepted to help strengthen arrangements.

While recent training and engagement with external support were positive steps, further work was required to ensure IPC systems were effectively implemented, monitored and embedded in practice.

The service ensured that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes occurred.

As part of our assessment, we undertook clinical searches. These demonstrated that the practice had made significant improvements since the previous inspection, particularly in medicines optimisation and the monitoring of high‑risk medicines. There was clear progress in the safe prescribing and monitoring of patients prescribed Direct Oral Anticoagulants (DOACs), with substantial reductions in patients without appropriate monitoring.

Staff followed processes to ensure people prescribed medicines requiring regular monitoring received appropriate review. A sample of medication reviews were of a good standard, with clear documentation and evidence of appropriate clinical reasoning.

The provider had systems to manage and respond to safety alerts and medicine recalls. Progress had been made in reducing risks identified through legacy Medicines and Healthcare products Regulatory Agency (MHRA) safety alerts. For example, the number of patients prescribed clopidogrel with omeprazole, where co-prescription should be avoided, had reduced from 24 to 5. The practice continued to review these patients as part of ongoing medicines safety monitoring.

We identified a small cohort of 166 patients (0.9%) aged over 65 who had been prescribed a non-steroidal anti-inflammatory medicine (NSAID) and/or an antiplatelet medicine without also being prescribed a medicine to help protect the stomach. The provider acknowledged this finding and confirmed that the cohort of patients would be reviewed. They also advised that this would be discussed at the next Multidisciplinary Team meeting (MDT meeting).

Staff managed medicines safely and regularly checked stock levels, expiry dates and storage temperatures for all medicines, including vaccines and emergency medicines. Medical gases were stored securely, and staff held appropriate authorisations under Patient Group Directions (PGDs).

Our review of prescribing data showed that the practice’s use of antibiotics was in line with expected local and national benchmarks. Prescribing antibiotics appropriately helps reduce the risk of antimicrobial resistance, which can make infections harder to treat.