Eastgate 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 rating remains the same.

This service scored 78 (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 strong proactive and positive culture of safety, based on openness and complete honesty. They actively listened to concerns about safety and thoroughly investigated and reported safety events. Lessons were always learnt to continually identify and embed good practice.

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 responded accordingly.

The service 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.

There was a Quality Assurance Lead with responsibility for monitoring all complaints and significant events. The service recorded 17 complaints between 2025 and 2026, and 4 significant events between 2024 and 2026. We saw that they were all recorded appropriately, investigated and responded to with learning shared with the whole team.

Managers encouraged staff to raise concerns when things went wrong. During staff meetings, the whole team discussed and learnt from clinical issues. Staff gave examples such as learning from delayed diagnosis, improvements in prescribing processes and improved access arrangements for patients with learning difficulties. Staff felt there was an open culture, and that safety was a top priority.

We saw evidence of learning from incidents being applied in practice. The Quality Assurance Lead gave an example of an incident involving an administrative error from the handling of blood test samples; the service had identified the risks related to patient identification and data breaches. As a result of this, the service strengthened its processes by introducing 3-point identity checks and reinforcing General Data Protection Regulation (GDPR) practices with the staff.

The service had clear oversight of their significant events and had carried out analysis to identify common themes, trends, and ongoing learning. For example, they identified a trend in events involving administrative or clinical-administrative workflow risks, particularly around patient identification, sample handling, and referral processes. Learning highlighted the need for simple, visible checks of identity, accurate documentation, and appropriate clinical escalation.

These actions were tracked through governance processes and reviewed at subsequent meetings to ensure completion and improve the reliability of systems and processes.

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. The service captured information when new patients registered at the practice including whether the patient was a carer, had communication and accessibility needs, or any other needs.

The service worked with other providers to deliver shared care and support people when they moved between services. Feedback from care home representatives was generally positive about the support provided by the service. Care home residents received regular clinical input from a range of practice clinicians, including face-to-face reviews, medicines reviews and ongoing multidisciplinary support. Feedback also identified opportunities to improve communication processes, access to timely clinical review and timeliness in resolving medication-related issues.

Referrals were managed well by the service. Referrals were prioritised with 2-week wait referrals being sent the same day, and other urgent referrals being sent within 24 hours. The service maintained a tracker of all their referrals, and urgent referrals were monitored and followed up to ensure they were actioned.

Communications received from other providers and test results were managed effectively. There were policies and protocols for managing correspondence and test results. Requesting clinicians were responsible for processing their own results; however, the workload was shared with other clinicians in their absence. Our review from clinical searches confirmed that correspondence and laboratory results were processed in a timely way.

The service worked well with people and healthcare partners to fully understand what being safe meant to them and the best way to achieve that. They had a clear focus on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They always shared concerns quickly and appropriately. It was clear that safeguarding was at the forefront of the service, with a strong and consistent focus maintained across all levels.

The service had a dedicated Safeguarding Team comprising a clinical safeguarding lead and deputy lead, a non-clinical safeguarding lead and safeguarding co-ordinators. Their roles were to oversee all matters relating to safeguarding and ensure the safe and appropriate handling of these. They worked closely with local organisations in the community such as school nurses, health visitors, local authority and domestic abuse services. The clinical safeguarding lead was also a named GP safeguarding lead for the ICB.

There was a named domestic abuse champion and staff who were trained as domestic abuse first responders. This specialist training enabled them to recognise and respond to domestic abuse concerns. They also helped raise awareness of domestic abuse across the service and organised related events and initiatives. Staff gave specific examples of how this role had made a difference to patients experiencing domestic abuse, including building trust with individuals, providing practical advice and guidance, and helping them engage with specialist support that they may not otherwise have accessed.

Safeguarding policies were in place, regularly reviewed and accessible to staff. There were separate policies for adults and children, and other protocols such as for child protection and working with sexually active young people, did not attend (DNA) policies and processes for reporting safeguarding concerns for both patients and non-patients.

All clinical and non-clinical staff completed safeguarding adults and children’s training to level 3 and were up-to-date with training. All staff had also undertaken and were up-to-date with chaperone training. Staff engaged in safeguarding training and learning through workshops delivered in collaboration with their sister practice. These workshops covered various topics of abuse, for example “honour-based abuse” and “cuckooing”, supporting staff to recognise a wider range of safeguarding concerns.

Staff we spoke with during our assessment knew their roles and responsibilities regarding safeguarding and were able to describe the process they needed to follow. They gave clear examples of what constitutes safeguarding and demonstrated confidence in recognising concerns and taking appropriate action. Staff also described examples of times when they had identified safeguarding concerns and taken appropriate action, including making referrals, which resulted in people being protected.

The service maintained a register of vulnerable patients and responded to concerns in a timely way, working in partnership with other organisations.

A programme of regular safeguarding audits was in place, including reviews of how the practice identified, managed and responded to domestic abuse, ensuring standards for safeguarding in general practice were met.

The service held a weekly Safeguarding Review Panel meeting which was attended by clinical, non-clinical and management staff. The panel reviewed new safeguarding concerns referred to the safeguarding leads and discussed ongoing and historic cases, which were monitored through a robust tracking system and use of data. The service also maintained a safeguarding tracker to support oversight and ensure appropriate follow-up.

The service developed safeguarding leaflets to support patient awareness and access to information. There were also posters in the practice and information on the practice’s website, including information for specific groups of people and what people could do if they had a concern.

The service worked proactively with its sister practices and Primary Care Network (PCN) to deliver initiatives for patients and the wider community. This included domestic abuse drop-in sessions designed to enable safe and discreet access. These initiatives enabled people to disclose experiences of abuse and access immediate support. Feedback from people who used the service demonstrated that they valued the opportunity to talk, increased their awareness of available support, and felt more able to engage with the practice.

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 were advised on risks related to their condition and how to keep themselves safe, including what to do and who to contact if their condition worsened or if they experienced any unexpected symptoms. Clinical and non-clinical staff were aware of actions to take if they encountered a deteriorating or acutely unwell patient.

Training records that the practice gave us for this inspection showed all staff had completed training in child and adult basic life support and anaphylaxis in the last year.

The service also required staff to complete training in sepsis awareness every year. Sepsis, sometimes called blood poisoning, happens when your body overreacts to an infection and starts to damage itself. Symptoms can be difficult to spot and sepsis can be life-threatening. Therefore, it is important that staff can recognise and act on symptoms. Records showed that all staff were up-to-date with this training.

The service held appropriate emergency medicines and had risk assessments in place that explained why medicines were, or were not, kept. There was a system in place to monitor the expiry dates of emergency medicines and equipment. During our site visit, we found all the expected emergency medicines to be available and in date. Staff were aware of where the emergency medicines were stored.

Emergency equipment was available and maintained. The service kept medical oxygen and a defibrillator on site, and there were systems to ensure these were regularly checked and fit for use. However, systems for making sure other emergency equipment such as consumables and sundry items were available and safe for use were not in place, which meant that some sundry items were not available. This identified that this area could be strengthened.

During our site visit, we identified concerns related to the accessibility of the medicines and equipment due to their storage location. Leaders responded immediately to our feedback by completing a risk assessment of accessibility and putting in place the necessary changes such as relocating stock, introducing grab bags, and developing an emergency equipment checklist. This provided assurance that any risks had been considered and mitigated.

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

Contracts were in place to ensure the premises were maintained. The service had various health and safety and fire safety policies and protocols. Risk assessments and audits had been undertaken by an external company in June 2026. All actions identified from these risk assessments had been addressed. There was a business continuity plan in place which was monitored and reviewed.

However, during our site visit we identified some inaccuracies in risk assessment documents conducted by the external company. This indicated that oversight of records undertaken externally needed strengthening. Leaders responded immediately to our feedback by contacting the external contractor and providing reassurance that this was a clerical error and that the risk assessments in place were otherwise correct.

The service also carried out monitoring of their water system for Legionella. These tests were undertaken by the service on a monthly basis and are important to identify if there is an increased risk of Legionella bacteria growing in the water system so that the required actions can be taken. This is important because if these bacteria are breathed in, it can lead to Legionnaires’ disease, a serious type of lung infection which can be fatal.

During our site visit, we saw various fire extinguishers throughout the building, which had been serviced appropriately, and clear signs directing people to fire exits, explaining the fire procedure and stating who the fire wardens were. Fire wardens had completed additional training to enable them to carry out this role safely.

There was evidence of regular fire drills and of actions taken in response to learning identified from them. The service provided records showing weekly checks of the fire alarm system and emergency lighting were carried out. All staff had completed and were up-to-date with fire safety training.

There were systems to ensure that electrical equipment was regularly tested and medical equipment regularly calibrated. This is important to ensure that it provides correct readings so that patients receive appropriate treatment. During our site visit, we saw that equipment was checked on an annual basis and was last tested in October 2025.

The practice had developed a comprehensive suite of control of substances hazardous to health (COSHH) policies, risk assessments and audit tools. Staff responsible for COSHH management were clearly identified and risks associated with hazardous substances had been considered.

During our site visit, we identified a potential risk in the downstairs waiting area used by patients with accessibility issues. The area posed a risk due to limited visibility in the event of a deterioration or other safety issue. The service responded immediately to our feedback by undertaking a risk assessment of the waiting area and taking immediate action to remove any risks identified.

The service always 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 service, which included GPs, nurses, healthcare assistants, physician associates, paramedics, physiotherapists and pharmacists. Staff had the skills, knowledge and experience to deliver effective care, support and treatment, and were working within their agreed areas of competence. There were enough staff to provide appointments, support continuity of care and prevent staff from working excessive hours.

Safe recruitment practices were followed. The service had robust systems in place to ensure staff were employed in line with safer recruitment processes, including ensuring that Disclosure and Barring Service (DBS) checks appropriate to the role were undertaken. During our assessment, we reviewed a selection of staff records and saw that most had the necessary documents available in line with their processes and regulatory requirements. Where documents were not available, service leads were aware and gave assurance that risks had been assessed before the offer of employment.

The service had a comprehensive training programme, and staff had protected time for learning and development. Training was up-to-date, and learning needs and staff development were managed appropriately. The service supported the development of all staff, and staff were positive about the learning and development opportunities available. This included day-to-day support for staff who were new to general practice roles. Staff told us their skills were recognised and they were encouraged to gain new skills and develop further, for example by progressing to lead administrative roles, taking on new projects, or becoming more specialist in clinical areas such as mental health.

The service maintained a tracker to ensure staff appraisals were completed in a timely way and that professional registrations were kept up-to-date. Staff had access to regular appraisals, one-to-ones, coaching and mentoring, and clinical supervision. Records showed that all staff had received an appraisal within the year leading up to this inspection, in line with the practice’s Staff Appraisal Policy. The service also had policies relating to staff training and development and could demonstrate how they assured the competence of staff working in advanced clinical roles, including nurses, pharmacists and physician associates, providing assurance that care and treatment were delivered safely and effectively.

The service demonstrated the prescribing competence of non-medical prescribers through regular review of their prescribing practice, supported by clinical supervision and a systematic process. A lead GP carried out regular audits of prescribing practices, consultations and clinical records completed by non-medical prescribers, helping to identify learning, maintain high standards and promote safe prescribing.

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 service had an infection, prevention and control (IPC) policy and a designated IPC lead, who was supported by a quality assurance lead nurse. The leads had undergone IPC training to support them in their lead role. They ensured staff had necessary knowledge and understanding by ensuring all staff completed annual training. Training records provided showed that all staff had completed and were up-to-date with their IPC essential training relevant to their roles.

Staff vaccination status was confirmed at recruitment. During our site visit we looked at a selection of staff records and found that staff had received all the recommended vaccinations.

Cleaning schedules were in place and followed. The practice regularly liaised with cleaning staff to address any concerns noted.

IPC risk assessments and audits were carried out; the most recent audit was undertaken in January 2026. Most actions identified through the audit had been completed, and those that were not had a clear plan for completion. However, the audit had not identified some IPC risks we saw during our site visit, such as plugs in some of the sinks, which could increase the risk of contamination. The service responded immediately to our feedback and provided evidence that the plugs had been removed.

The service made sure that medicines and treatments were safe and met people’s needs, 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.

There was a process for the safe handling of requests for repeat medicines and evidence of effective medicines reviews.

Our clinical searches confirmed that the practice carried out comprehensive medicine reviews. We looked at a sample of 5 records and found the reviews had been undertaken by an appropriately qualified clinician and were of good quality. They included all repeat medicines and checks that any required monitoring was up-to-date.

There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.

Benzodiazepines and Z-drugs are medicines used to treat anxiety and sleep-related conditions, but long-term use can lead to dependence and increase the risk of falls, memory problems and other side effects. We found 28 patients who had been prescribed benzodiazepine medicines or Z-drugs more than 10 times in the last year. We looked at the records for 5 of these patients and found the medicines had been reviewed and prescribed appropriately for all patients, with evidence that attempts had been made to wean patients off the medicines.

The service had recently undertaken an audit of patients prescribed long-term benzodiazepines and Z-drugs to ensure their prescribing was in-line with national guidance and to reduce the risks associated with dependence-forming medicines. They found that 25 of 28 patients (89%) had received a specialist pharmacist-led structured review, with the remaining patients appropriately tracked and awaiting review. This improved monitoring of patients taking these medicines, helped identify opportunities to safely reduce treatment where appropriate, and reduced the risk of harm such as dependence, falls and memory problems.

Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes. Prescribing data reviewed as part of our assessment showed that the prescribing of hypnotic medicines such as benzodiazepines, gabapentin and pregabalin was in line with the local and national averages. The service was also in line with local and national averages for prescribing psychotropic medicines.

The service was aware that their prescribing of antibiotics for urinary tract infections (UTI) was higher than expected. The service had previously undertaken an audit of UTI antibiotic prescribing, which found that the correct antibiotics were usually prescribed, but there were some areas for improvement, including the length of treatment, and the use of diagnostic tests. In response, the service reviewed national guidance with staff, promoted the use of other services such as “Pharmacy First” where appropriate, and took steps to improve prescribing and testing practices.

The service demonstrated oversight of people’s prescribed medicines that required regular monitoring. Staff followed protocols and carried out regular searches of the clinical system to make sure reviews and monitoring was appropriate and completed in recommended timescales to ensure it was safe for patients to still be prescribed the medicine.

Our searches showed that patients prescribed high-risk medicines had received the necessary monitoring to make sure it was safe to continue prescribing and that the dose prescribed was suitable. This specific and regular monitoring is needed because of the risks associated with taking the medicines.

During our search of the practice’s clinical system, we reviewed patients prescribed methotrexate, a high-risk medicine used to treat inflammatory conditions, such as rheumatoid arthritis. We found all monitoring to be appropriate and up-to-date.

We also reviewed 5 records for patients prescribed an angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB). These are medicines used to treat high blood pressure and heart failure. We found all monitoring to be appropriate and up-to-date.

The service had effective systems to manage and respond to safety alerts and medicine recalls. They maintained a patient safety alerts tracker. During our search of the clinical system, we reviewed 5 patients prescribed topiramate (a medicine used to treat seizures or migraines), where an alert required that women of childbearing age must be informed of the risk of harm in pregnancy. In all cases, the associated risks had been discussed and documented.

The service ensured medicines were stored safely and securely, with access restricted to authorised staff. Medical gases, including oxygen, were also stored safely. During our site visit, we found that room temperature checks for medicines were not being completed in line with the service's medicines management policy. Leaders and staff took prompt action to address this following our feedback.

Medicines, including vaccines and emergency medicines, were stored securely and monitored to make sure they remained safe and effective. Staff regularly checked stock levels and expiry dates. We found that vaccines were kept at the correct temperatures and fridge temperatures were recorded daily. The service also had backup systems, including a data logger, to continue monitoring temperatures if the fridge thermometer stopped working.

Staff managed prescription stationery appropriately and securely and in line with the service’s medicines management policy. Blank prescriptions were kept securely, and their use monitored in line with national guidance.

Staff had the appropriate authorisations to administer medicines, including Patient Group Directions (PGDs) and Patient Specific Directions (PSDs). A PGD provides a legal framework that allows specific registered health professionals to give a named medicine to certain groups of patients, without the need for an appropriate clinician to issue individual prescriptions.

Staff told us how they used PSDs safely and effectively. Prescribing clinicians can use PSDs to instruct non-prescribing staff, such as healthcare assistants, to give a named medicine to certain individual patients who the prescriber has assessed need the medicine.