Holbrook 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 good. At this assessment, the key question has been rated as requires improvement.

The service did not have consistently effective processes to identify and share learning from incidents and significant events. The service did not have safe and secure systems to manage medicines, their associated risks and related stationery. The service did not always effectively mitigate and control potential risks within the care environment. The service assessed and managed the risk of infection, although could not evidence cleaning checks in the dispensary. Staff were qualified, experienced, and received training, although gaps were identified in recruitment and induction records, role specific training and some appraisals were overdue. However, safeguarding arrangements were effective to ensure people were protected and kept safe.

The service was in breach of legal regulation in relation to safe care and treatment.

This service scored 56 (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 consistently demonstrate a proactive and positive learning culture of safety. Processes were in place for staff to report incidents, near misses, and safety events, however incidents were not all recorded on the service’s log. Leaders did listen to concerns about safety. However, they did not always identify, record and share actions for learning. Although learning was shared with staff directly involved, lessons were not always shared to continually identify and embed good practice and improve care for others. The provider acknowledged processes to share learning were not always effective and had planned action to improve this.

We did not receive feedback from people regarding their experiences for this quality statement. Representatives from the Patient Participation Group (PPG) told us members were able to raise issues on behalf of people who used the service and felt listened to.

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. People, including care home representatives, gave positive feedback in relation to the registration process, the follow up from blood tests and investigations, and timely, appropriate referrals being made.

Protocols were in place to manage the flow of work. People’s correspondence which was deemed urgent, for example, urgent test results were prioritised. Arrangements were in place to ensure actions from these were reviewed and authorised by an appropriate clinician. Audits of the work of non-clinical staff were undertaken and any issues identified were discussed and used to support learning.

Staff who were involved in making referrals were clear about their role. Referrals and test results were managed in a timely way. A range of audits were in place for example, to ensure people had been seen, results received and follow up arrangements were in place. However, there was no effective system to ensure results were received for every cervical screening sample sent. This was addressed immediately, with strengthened arrangements and planned oversight to ensure ongoing monitoring.

The service worked with other providers to deliver shared care and when people moved between services. Partner agencies who provided feedback for this assessment had no specific views or concerns in this area.

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 and known to staff, who were appropriately trained in safeguarding procedures. Staff who we received feedback from told us they were confident to report any concerns and the service safeguarding leads were knowledgeable.

The service maintained a list of vulnerable people and acted on concerns working in partnership with other organisations. Arrangements were in place to follow up vulnerable people who had not attended for their appointment, which included for example, secondary care appointments. Safeguarding discussions took place during bimonthly safeguarding and multidisciplinary meetings.We reviewed minutes of these meetings and people’s needs were discussed and reviewed, and actions agreed and followed up.

Partner agencies who provided feedback for this assessment had no specific views or concerns in this area.

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.

People who provided feedback for this assessment had no specific views or concerns in this area. People were advised on risks related to their condition and actions to take if their condition deteriorated.

People in the waiting room were easily visible to staff so they could identify and respond to any people whose health may be deteriorating. Arrangements were in place for staff to identify, assess and manage people whose health was deteriorating, and for managing medical emergencies. Staff had completed training, relevant to their role and staff we spoke with told us they could recognise when a person’s health was deteriorating and knew of action to take. A duty GP was available every day for advice and support as necessary.

The service did not always effectively mitigate and control potential risks within the care environment. Facilities were not consistently managed to ensure the delivery of safe care.

Arrangements were in place to ensure risk assessments were completed. These included for example, health and safety, fire, legionella and disability risk assessments. We found most actions had been completed. However, for example, an action in the fire risk assessment completed in January 2026, and identified for immediate action, had not been completed. Following the site visit, the provider confirmed approval had been given for this action to be completed. In addition, weekly fire alarm tests were not completed. Monthly water temperature checks were not consistently completed, there were no records to demonstrate that weekly flushing of water outlets had been completed, and there was a lack of oversight to ensure these control measures were being monitored and maintained. Weekly tests planned for audible and visible alarms could not be evidenced. However, there were checks for electrical safety, and equipment calibration.

Staff told us they had suitable and sufficient equipment to undertake their work and were satisfied with the health and safety arrangements in place. Staff used technology securely and effectively with arrangements in place for the confidentiality of data management. The service had an up-to-date business continuity plan which covered environmental risks and was monitored and reviewed.

The service made sure there were enough qualified, skilled and experienced staff, who received support, supervision and development, although some staff appraisals were overdue. While mandatory training completion was good overall, gaps were identified in recruitment records, induction documentation, and some role-specific training.

We reviewed the records of 2 members of staff. There was evidence of identity checks, review of qualifications and Disclosure and Barring Service (DBS) checks. However, no references were obtained for 1 staff member and only 1 reference was available for a second staff member. The Practice Manager was able to evidence that 2 references had been obtained for a staff member who had recently been offered a position but not yet commenced employment. The professional registration of clinical staff was checked at recruitment and on an ongoing basis.

Induction records had not been signed to confirm completion for 1 staff member and could not be evidenced for a second staff member. The Practice Manager showed us a recently completed and signed induction for a Primary Care Network staff member, who confirmed their induction had been comprehensive. (Primary care networks are groups of GP practices who work together to improve primary care services).

Leaders ensured staff were up to date with training the service had deemed mandatory. Staff we spoke with told us they worked within their agreed areas of competence. Informal arrangements were in place for the clinical oversight of clinical staff working in extended roles, which included those who prescribed medicines. The provider had strengthened their arrangements and recently introduced a formal audit. This needed to be embedded into practice. A duty clinician was available for clinical advice and support, for example to discuss home visits and post home visit support. Some staff appraisals were overdue by up to 3 months and following the site visit the Practice Manager confirmed team leads had been advised to hold staff appraisals by the end of the month.

Feedback from people, which included care home representatives, was positive in relation to the knowledge, skill, care and treatment provided by clinical staff. Feedback was also positive regarding the attitude of staff.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies. However, cleaning schedules and audits of cleaning were not in place for the dispensary.

The service had a designated infection, prevention and control (IPC) lead who conducted regular risk assessments and audits to ensure compliance and took action where necessary to mitigate any identified risks. A minor surgery reaudit was planned.

During our on-site visit, the service's premises and a sample of equipment reviewed were observed to be visibly clean. We checked a sample of identified actions from the latest IPC audit and found these had been completed. Cleaning schedules were available and provided clear guidance on the cleaning of the premises and equipment. The service demonstrated how these were monitored for completion to maintain effective oversight of cleaning arrangements. However, these were not in place for the dispensary. The provider obtained confirmation from the external cleaning company these areas were cleaned and planned to review the arrangements in place. Appropriate arrangements were in place to manage clinical waste.

Staff had completed training relevant to their role and told us about the systems in place for safely dealing with clinical specimens and spilt bodily fluids. Staff immunisation records had been reviewed and an action identified for 1 staff member was underway.

People and care home representatives we spoke with had no concerns regarding infection prevention and control.

The service did not have safe and secure systems to manage medicines within the premises, their associated risks and related stationery. There was limited oversight of the risks.

The service included 2 dispensaries, 1 at each site. Only authorised people had access to the dispensaries. The dispensaries did not have enough storage space which meant completed prescriptions were stored on the benches, limiting the area for working safely. There was a separate well organised designated area used to prepare blister packs for people who had been identified as needing them.

There was no record of the cleaning schedule or cleaning logs for the dispensaries. Tap water from the sink in the dispensary was used to make up antibiotic syrups including those for babies. Babies less than 6 months old are not recommended to drink tap water and should receive sterile water. This was actioned immediately by the service.

Staff told us about workforce shortages, which meant staff were pulled from other areas of the service to cover dispensary activities and it was difficult to complete routine tasks. We saw that monthly controlled drug (CD) checks had not taken place; there was a 4-month gap in the CD register. Staff told us they couldn’t complete the expiry date checking of medicines held at the service as per policy. Prescription stationery was not managed appropriately; the tracking logs had not been completed.

The provider had recently changed to 7 working days’ notice for repeat prescriptions due to capacity issues as they were unable to meet their 5-day target. The service was in the process of hiring additional staff and purchasing the necessary additional equipment to increase capacity.

Not all emergency medicines were available for use within the service, for example benzylpenicillin was not available at the Holbrook site to treat suspected meningitis, this was actioned immediately. A risk assessment completed in March 2026 stated that dexamethasone was available in the CD emergency bag for Shotley, but it was not available on the day of our assessment. Following the site visit the provider confirmed this was now in place. The documentation used to monitor the emergency medicines did not provide assurance that regular checks were taking place.

Vaccines were well managed and kept within the recommended temperature ranges in a monitored fridge within the nurse’s room. However, within the dispensary at Shotley, 1 of the fridges had been recorded as exceeding maximum recommended safe temperatures on 5 separate occasions during April and May 2026. There was no record of which staff were completing the checks and any actions taken. The provider offered a delivery service, however there was no monitoring of the temperature when transporting medicines that require cold storage to ensure they remained at the required temperature. Although a cold chain policy was in place, it did not include arrangements for temperature monitoring when transporting medicines and it was not consistently followed in practice.

Staff followed established processes and standard operating procedures (SOPs) were in place for dispensaries activities. However, there was no SOP in place to cover the dispensing of some high-risk medicines. This is necessary to ensure that the correct monitoring had been completed before dispensing occurred. Where staff made changes to medicines records there was no consistent process when the GP had authorised the changes so staff knew that dispensing could occur.

Our clinical searches showed that people received the correct monitoring when prescribed medicines by the service but did identify that occasionally people had not received steroid cards when they should have. It was unclear to staff in the dispensary when it was appropriate to issue these steroid cards.

Medication incidents that were being recorded by the dispensary team were not always on the significant event log that was reviewed by the service. No regular dispensary meetings were taking place, the last one was in February 2026, where the need for data loggers for the dispensary fridges had previously been identified. The dispensary team were not included in wider service learning and communication.

Prescribing data identified a negative trend for antibiotic indicators for the number of antibacterial prescriptions issued and the length of course of antibiotics prescribed for urinary tract infections. The service was unaware of this data and did not routinely look at their antibiotic prescribing.

Patient Group Directions (PGDs) were in place to allow the nurse to give vaccinations without a prescription, and these had been appropriately authorised for use.

The dispensary was part of the Dispensing Services Quality Scheme (DSQS) and completed annual audits and as part of last year’s audit we saw that actions had been taken to improve the repeat dispensing procedure.

We received feedback from care home representatives who told us the repeat ordering process generally worked well, and staff answered and dealt with any queries effectively. They told us people’s medicines were reviewed.