St Thomas Road 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. Overall, we found that the service provided safe care and treatment, although there were some areas of clinical records management and medicines management and optimisation which needed improvement. Safeguarding practices were thorough and embedded within the service.

At our last inspection, we rated this key question as requires improvement due to concerns regarding patient recall processes, the monitoring of patients on high-risk medicines and long-term conditions, and the actioning of safety alerts. 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 provider had a proactive and positive culture of safety, based on openness and honesty. The practice had policies and systems in place to manage significant events, incidents and complaints.

We saw that the provider listened to concerns about safety and investigated and reported safety events. To support this activity the provider had developed a complaints and comments procedure and a significant events procedure, both of which were kept regularly updated. Staff we spoke with or received feedback from knew steps to take when complaints were raised with them or if they identified a significant concern. Over the previous 12 months the provider had received 5 complaints and had identified 10 significant events. We reviewed these and saw that these had been handled appropriately, and that required actions had been taken to prevent recurrence. Learning from incidents and complaints was shared with staff at meetings or individually. For example, we saw within clinical meeting minutes that staff discussed complex patients, complaints and significant events.

The provider had undertaken a number of clinical and non-clinical audits to support and drive service improvement. As an example, the provider had identified the practice as a higher than average prescriber of anxiolytic and hypnotic medicines (a range of medications aimed at treating patients with panic disorders, generalized anxiety, and insomnia, and which can have dependence or withdrawal issues). In 2022 they had undertaken an audit into the prescribing of these medicines and had put in place measures to reduce patient usage. Measures included running searches to identify patients, and recalling patients for structured medication reviews. A reaudit undertaken in February 2025 showed that average daily quantities prescribed had moved the practice from the 97th percentile to the 63rd percentile. Patients had been supported to move to other medications or had active controlled reduction plans in place.

Overall, 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 there was continuity of care, including when people received care from other services.

We saw that there was a policy and systems in place to manage referrals, this included cancer 2-week wait referrals, and the tracking of referrals to ensure that patients attended appointments and had received their required care and treatment. In addition, we saw that the provider had systems in place to deal with incoming correspondence and test results.

However, we also found during our remote clinical searches that there were over 500 open tasks in the practice’s patient management system (these are action items for healthcare professionals to manage a patient's care). The provider informed us that the majority of open tasks were used as reminders to follow up actions. In addition, the provider had a substantial summarising backlog of 1,452 incoming patient records which needed actioning. We discussed this latter point with the provider who told us that in mitigation the vast majority of patient information came via the electronic transfer of patient records, and that transferred patients completed a new patient questionnaire which sought to identify key information such as health conditions and allergies. However, the provider had no defined plan of how to deal with this backlog at the time of the assessment.

The provider had appointed a safeguarding lead and deputy for both adults and children and had separate safeguarding policies in place for both adults and children. Both clinical and non-clinical staff had undertaken training to the level appropriate to their role.

Staff we spoke with or received feedback from knew who the safeguarding lead was, how to access the policy, and felt able to escalate concerns when these were identified. The practice worked with others when safeguarding issues were raised, and we saw evidence that safeguarding concerns were discussed at weekly clinical meetings.

There was a policy for chaperoning and staff had undertaken training as required. Staff had Disclosure and Barring Service (DBS) checks as necessary.

Staff at the surgery worked with patients to understand and manage risks. We saw that staff provided care to meet patient needs that was safe, and supportive. Results from the 2025 National GP Patient Survey showed that 96% of patients reported that they were involved as much as they wanted to be in decisions about their care and treatment during their last appointment, compared to local and national averages of 91%.

Emergency equipment was available and maintained, and there was guidance in place that outlined where the equipment and medicines were for emergencies. The provider had systems in place for the checking of emergency equipment and medicines, and we saw that this was undertaken on a monthly basis.

Mandatory basic life support training covered both adults and children, this was provided face-to-face for clinical staff annually, and for non-clinical staff 3 yearly. During the assessment, the practice implemented a risk assessment to support the gaps within annual resuscitation training for non-clinical staff. Staff told us that they were aware of raising an emergency and knew ‘reg flags’ or could access support easily through posters and care navigation templates.

During the assessment it was initially unclear whether all staff had been assigned to complete or had completed training for sepsis. The practice later shared evidence of staff certificates and confirmed that this module had been completed on induction as standard for all staff, but this had not been recorded fully on their training records. As a result of our findings the provider had updated the training matrix to reflect this. 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.

The facilities and premises were appropriate for the services being delivered. At our on-site assessment we observed the premises to be clean, accessible and appropriate for the activities being carried out. We reviewed the premises and facilities documentation and found that the practice was aware of all potential risks and managed these effectively. For example, a fire risk assessment undertaken in May 2025 had identified the need to clear vegetation from outside the emergency rear fire exits, and to extend emergency lighting to the disabled toilet. We had confirmation from the provider that the emergency fire exits had been cleared of overgrowing vegetation, and emergency lighting had been requested and was awaiting installation. Following our on-site visit the provider had updated their control of substances hazardous to health (COSHH) assessments to include urine and vomit spill kits and liquid-based cytology pots.

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.

There were a range of clinical and non-clinical roles within the practice, which ensured patient needs could be met safely and effectively. The provider had a recruitment policy in place and during the assessment we reviewed 2 clinical and 2 non-clinical recruitment files of staff that had been employed since the previous inspection. Within these files there was only 1 member of staff without a signed contract. All other documentation was in place, showing that the practice had obtained the relevant documentation during the recruitment process, had an induction process in place and were conducting appraisals and performance reviews.We were told by the provider that the staff member would be asked to sign their contract formally at the soonest opportunity.

The provider had processes in place to assess and record the immunisation status of staff. During the assessment, the provider told us that they gave staff the option to have any missing immunisations given within the surgery. The provider had information for staff advising of local occupational health services, and declaration forms explaining risks for any missing immunisations that were declined. Despite the comprehensive oversight and risk assessments, the practice staff undertaking these immunisations did not have specific training for this role. The provider advised us since our visit that they would utilise occupational health services going forward for undertaking necessary staff immunisations.

The provider had induction processes in place for all new staff including support for agency or locum staff. We saw evidence that new staff had received performance reviews during their probationary period. In addition, the provider had regular appraisal procedures in place for all staff, and staff confirmed that they had either received a recent appraisal or had one planned.

We saw that clinical supervision had been undertaken for staff including non-medical prescribers. Records that we reviewed were detailed, and the underpinning clinical supervision policy clearly outlined the roles and responsibilities of the supervisor and supervisee, and the process to be followed.

Overall mandatory training had been undertaken and was satisfactory, any missing training had been completed by staff during our assessment. However, we found that the training matrix did not accurately reflect role-specific training and competencies staff had completed.Following our assessment visit the provider confirmed that the evidence of role-specific training would be added to their training matrix.

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.

We saw that the provider had a designated infection, prevention and control (IPC) lead and all staff had had received relevant IPC training. There was an IPC policy in place which outlined the provider’s approach to the management of infections and covered key areas such as cleaning and disinfection, and outbreak control and notifications.

We saw that an IPC audit had recently been undertaken, and that identified issues had either been actioned, or would be actioned during building and refurbishment works which were due to be completed in 2025. Overall, the premises was found to be in a clean and clutter-free condition. We identified some minor issues in respect of cleaning equipment and storage within the domestic staff’s cupboard, and were informed by the provider that these would be addressed with their team.

Overall, the service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. The provider had processes in place for the management and oversight of prescribing including clinical supervision processes and audits. Prescribing data for the provider showed that it was either in line with or slightly better than local and national comparators.

Whilst we saw that medicines had generally been prescribed safely such as those patients in receipt of Methotrexate and Azathioprine, there were some areas our remote clinical searches showed which required improvement. This included, of 54 heart failure patients prescribed Aldosterone Antagonists, 10 had potentially not received the required monitoring. Following our feedback the provider had investigated this further and had reviewed the identified patients, as well as putting in place more robust measures to identify and recall patients for necessary monitoring. In addition. we found that 55 of 185 elderly patients prescribed an oral non-steroidal anti-inflammatory drug (used to reduce pain, lower fever, and decrease inflammation) aged over 65 years, or over 75 years and prescribed antiplatelets, were not potentially in receipt of proton pump inhibitors as outlined in national guidance and were at risk of a gastrointestinal bleed. After we raised this with the provider, they started to review all patients potentially at risk, placing some of those if appropriate and agreed on the necessary proton pump inhibitors, and also raising the awareness of the guidance with clinicians. We also identified 6 patients who were prescribed over 10 medicines (polypharmacy) and had not received a polypharmacy review in the last 18 months. The provider acknowledged that this cohort of patients fell outside their usual recall and review processes, as despite having multiple conditions they did not have a long-term condition. After undertaking some further work the provider found that some of these patients had been reviewed, but that this work had not been coded into the patient record. Notwithstanding this, the provider had also put in place measures to improve performance in this area which included running enhanced patient searches to identify when reviews were due, and only issuing prescriptions for a maximum of 12 months for these polypharmacy patients as well as undertaking reviews at reauthorisation.

The provider had systems to manage and respond to safety alerts and medicine recalls. However, during our searches of safety alerts we found that an alert concerning SGLT2 (a medicine used to treat type 2 diabetes) had not been actioned, and of 5 records we checked no patients had been informed of risks associated with the medication and warning signs to be aware of. After discussing our findings with the provider, they had sent patients the necessary advice and coded this into their patient records. They also introduced other actions including arranging for advisory letters to be sent to patients (rather than by text) if a patient did not have a mobile phone and adding SGLT2 to their monthly searches to enhance their own surveillance processes. In addition, it was initially unclear in the patient record if an alert concerning the teratogenic drug (a medicine which is linked to birth defects) Topiramate had not been actioned and that patients had not been given appropriate information and support. However, the provider was able to later clarify that actions in respect of these patients had been carried out. Furthermore, the provider retrospectively updated each record to document the necessary actions. We were also informed that the provider had introduced additional searches to ensure patients in receipt of this medication were supported in an appropriate manner.

Staff received regular training, were competency assessed on medicines optimisation, and felt confident managing the storage, administration and recording of medicines. We saw that staff managed prescription stationery appropriately and securely.