Archived: Seaforth Farm 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

At our last inspection, we found significant events were not well managed; the practice did not assure themselves of staff competency when undertaking minor operations and prescribing medicines. Fire and water safety systems where not up to date. The practice did not have an effective system for recording and acting on safety alerts. Systems for ensuring emergency medicines and equipment were fit for use, were ineffective.

At this inspection we found the practice had made improvements in relation fire and action on safety alerts. However, insufficient improvements had been made in the other areas, and serious additional concerns were identified.

We identified repeated breaches of Regulations 12 (safe care and treatment) and 18 (staffing) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 as set out in the warning notice issued on 4 September 2025. The provider was required to be compliant by 6 December 2024.

This service scored 44 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

At our last inspection we found the practice did not have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

At this inspection staff knew how to identify and report concerns, safety incidents and near misses. However, staff told us that if they did raise concerns, these were still often ignored or dismissed. They talked about a ‘blame culture’ where safety was not seen as a top priority. There was limited evidence to demonstrate the practice identified, acted on and learned from incidents and significant events. For the significant event records we looked at, the practice had not taken appropriate action to prevent re-occurrence. The practice had not raised significant events in relation to the known backlog of test results and the delays to patient care and treatment. Partners at the practice had ignored concerns raised by staff about this.

The practice did not maintain safe systems of care. They had not managed or monitored patient safety.

Referrals and test results were not managed in a timely way. During our site visit on 7th August 2025, we identified a backlog of 495 blood tests results which had not been reviewed with the oldest dating back to 22 July 2025. We identified 254 of these results were urgent, abnormal or seriously overdue. The practice told us this was because they had decided not to extend to extend the employment of 2 locum GPs, whose role it was to review test results. However, they had failed to make alternative arrangements for this. When we looked at patient records in more detail, we identified delays in potential cancer diagnosis and treatment, and delays in diagnosis of and treatment for heart failure. The results were not reviewed in line with the practice’s protocols for viewing and acting on urgent test results.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

At our last inspection the practice was unable to provide assurance that it had acted to ensure the safety of patients and staff in identifying and managing the risk of fire. It failed to ensure appropriate monitoring of emergency medicines and equipment systems.

At this inspection we saw that an up-to-date fire risk assessment had been conducted in September 2024 and that all actions to mitigate risk had been completed.

Systems for ensuring emergency medicines and equipment were fit for use, remained ineffective. The practice did not hold all recommended emergency medicines and policies, and risk assessments were not in place to determine the range of emergency medicines held. Systems to monitor stock levels, expiry dates, and to check that emergency equipment was fit for use were ineffective. We identified items were out of date (syringes and face mask). Some items were missing including a child pulse oximeter, airways, an ‘ambubag’ and portable suction. There were 2 adult pulse oximeters, 1 was in working order, the other was not fit for purpose indicating they had not been checked. We found that the storage of emergency medicines ‘grab bags’ did not enable prompt access to necessary medicines.

At our last inspection the practice was unable to demonstrate how it assured the competence of staff employed in advanced clinical practice, for example, nurses, paramedics and clinical pharmacists. It could not demonstrate the prescribing competence of non-medical prescribers. For one staff member undertaking minor surgery in the practice, no audits of minor surgery had been undertaken and there was no evidence an accredited Direct Observation of Procedural Skills (DOPS) assessment for this clinician.

At this inspection we found that some improvements had been made. For example, the practice had conducted audits of consultation notes for locum GPs and clinicians working in advanced clinical practice. We also saw evidence of regular group supervision meetings for those staff. However, there was no evidence that clinicians working in advanced clinical practice or in non-medical prescribing roles had an agreed scope of practice. In addition, the practice was unable to provide any evidence of regular review of their prescribing practice. There was limited evidence of effective clinical supervision with an appropriate clinician. Staff told us that whilst they had one to one meetings with a clinical supervisor these were unstructured and not always helpful. We saw notes of these meetings which were brief and lacked detail about what was discussed.

Improvements for minor surgery were insufficient. The practice provided details of two audits of minor surgical procedures that had been undertaken since our last inspection. However, the audits did not include any details about the patient, the type of procedure, the clinical diagnosis, outcome or patient satisfaction. There was still no evidence that this staff member had undertaken accredited DOPS training to ensure safety of patient procedures.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

At our last inspection, remote searches of the practice’s clinical systems, including a review of patient records indicated that not all patients received appropriate healthcare support. The practice was unable to demonstrate that effective reviews of patients’ medicines were always undertaken. The system for recording and acting on safety alerts was ineffective. Staff did not always have the appropriate authorisations to administer medicines.

On 12 August 2025 we conducted remote clinical searches and found that some improvements had been made. However, we identified ongoing and additional concerns with the process for monitoring patients’ health in relation to the use of medicines.

At this inspection we saw that safety alerts had been acted on and that improvements had been made to the identification of patients identified as having a potential missed diagnosis of chronic kidney disease.

However, the practice was still unable to demonstrate that effective reviews of patients’ medicines were always undertaken. Our clinical searches identified 1003 patients who had received a medicine review in the last 3 months. We looked at 5 patients in more detail. We found that medicines reviews did not always contain necessary information to support continued prescribing. Information was not always available to demonstrate what was considered as part of the review; whether any interactions of prescribed medicines had been discussed and considered with the patient; or any record of potential risks and actions to be taken.

We identified 74 patients prescribed a medicine used to treat and prevent bone-related conditions for 5 years or over. We looked at 5 records in more detail and found that none had been reviewed in the last 5 years to ensure the prescribed medicine remained appropriate.

We identified 68 patients diagnosed with hypothyroidism who had not received monitoring for a minimum of 18 months. We viewed the records for 5 patients and identified necessary monitoring was overdue for all patients and most recent test results had been outside the normal range. This meant that they may be suffering from signs and symptoms of under or over treatment with their medicine.

Staff were still not appropriately authorised to administer medicines. Patient group directives (PGDs) were not managed and authorised in line with guidance. (A PGD is a written instruction signed by a doctor/dentist and a pharmacist that allows certain registered health professionals to supply and/or administer a specified medicine). They were either not dated correctly by authoriser or not signed at all. We saw staff member 1 who was not yet sufficiently trained to administer immunisations was included on and had signed a PGD. We also saw that prescriptions initiated by non-prescribing clinicians were authorised by GPs without any review or assessment of the patient.