The Caxton 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 inspection, we rated this key question as Requires Improvement. At this assessment, the rating remains the same.

The service was no longer in breach of legal regulation in relation to providing safe services, however, we found the service was in breach of legal regulation in relation to good governance.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice had a process for reporting and recording significant events and had recorded a total of 5 significant events for the last 12 months. Staff told us they felt able to raise concerns and that there was an open culture. There were opportunities to discuss any learning from these events and staff were able, when asked, to give an example of a recent event that had been discussed.

There was a system for recording and investigating complaints. However, complaint records we sampled were inconsistent, contained some gaps and did not follow the practice complaint policy. For example, one of the complaints we sampled had been acknowledged, but there was no outcome letter on file outlining the next steps or advising the patient of escalation routes should they not be happy with the outcome of their complaint. For another complaint, the original complaint form was not on file, and it was not clear when the complaint had been acknowledged, as there was no record of acknowledgement. This was discussed with leaders during our site visit. They told us the complaint had been acknowledged verbally. We found the response to the complaint was sent later than the stated aim of 20 days and it did not include details of the escalation route, for example the commissioner or the Parliamentary and Health Ombudsman. For a third complaint, we saw that an apology had been offered in addition to an offer of a face-to-face meeting to discuss options. There was evidence that complaints were discussed practice wide, and any learning and themes were shared.

The practice 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. Staff told us that the practice had dedicated staff in post to manage the processing and summarising of information relating to new patients. The practice worked with other providers to deliver shared care and when patients moved between services. There was a system for monitoring referrals, including urgent referrals, and follow-up action would be taken in the event of a patient not receiving an appointment.

At the last inspection, we found that not all staff had received the appropriate level of safeguarding training required for their role. At this assessment, staff told us and records indicated that they had since received the appropriate level of training for their role. Safeguarding policies were in place and accessible to staff. Staff spoken with knew which individuals held lead roles for safeguarding children and vulnerable adults.

At the last inspection, we found that whilst patients with safeguarding concerns, including children and their siblings were coded on the clinical system, there were no codes or alerts routinely placed on the records of adult household members of children with safeguarding concerns. At this assessment, we found the practice had updated their records to rectify the omissions.

The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations. Regular meetings were held to discuss cases and share any recent updates.

The practice worked with people to understand and manage risks. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Emergency equipment was available and maintained. Staff were able to clearly and precisely demonstrate the process of the weekly checking of the emergency equipment, which included written documentation. Quantities of emergency equipment were not documented on the written documentation, relying on individual memory recall, which would make investigating missing stock difficult. Staff could recognise a deteriorating patient with the support of care navigation protocol and understood the necessary action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

The practice had a designated health and safety lead. They told us they had completed training to support them in their role.

The practice did not always detect and control potential risks in the care environment. They did not consistently make sure that equipment and facilities supported the delivery of safe care. The testing of portable appliances had been completed in January 2025 and the medical calibration of equipment had been completed in August 2024. Health and safety risk assessments and audits had been undertaken, however risks identified had not been addressed in a timely manner. For example, an electrical installation condition report (EICR) to reduce the risk of fire had been carried out on the premise in November 2022 and found unsatisfactory. An independent health and safety risk assessment carried out in October 2024 identified this had not been actioned and gave a completion date of December 2024. However, the identified work had not been carried out or completed until 5 July 2025. A certificate was obtained by the practice on the day of our site visit on 16 July 2025. Other actions in the risk assessment had not been completed within the documented timescale. We also found 2 staff worked from a room where a significant amount of patient paper records was stored. This had not been risk assessed in relation to the potential fire risk given all the electrical equipment present. However, following our site visit the practice carried out a risk assessment for this room and shared this with us.

A fire risk assessment had been carried out in 2020 by an external health and safety consultant and reviewed in 2023. The suggested date for review was March 2024. We were advised this review had been scheduled to take place on 29 July 2025. In addition, the use of portable electric fans had not been risk assessed or the vulnerable or restricted areas within the practice used by patients, such as the annex waiting area that was not staffed. Consideration had been given to the services offered in the annexe for example, non acute services such as counselling, wound care and pharmacist support, but risk assessment had not been formalised. Following our site visit the provider told us they were looking into formalising a risk assessment for seeing patients in the annexe/extension area and any reasonable and practical changes to ensure the safety of staff and patients.

The practice had a health and safety (HS) policy in place; however, according to the records we reviewed on site this had not been reviewed since November 2020. The policy stated it would be reviewed annually by the external company in conjunction with the nominated responsible person for the practice. Following our site visit the provider sent us a copy of their updated HS handbook, policy and statement, which was signed and dated post our site visit. They told us that those reviewed were the printed hard copy versions.

There was a business continuity plan in place which was monitored and reviewed and could be accessed remotely. Staff told us of the supporting relationships that they had with other local practices in the area.

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

There were a range of clinical and non-clinical roles within the practice. At the last inspection, we found that there was no formal monitoring of the non-medical prescribers. At this assessment, the practice offered supervision every 6 to 8 weeks. The practice shared their clinical supervision policy with us.

We found most training was up to date, learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence. There was evidence of staff induction on the 6 staff files sampled, however this was not role specific for clinical and non-clinical staff. Staff told us that they received regular training and that there were good opportunities for professional development.

Safe recruitment practices were not followed. The practice was not working in line with their recruitment policy and did not have the appropriate processes for assessing and checking staff offered employment were fit and proper persons. We sampled 6 personnel files for staff that had been employed since the last inspection. Omissions included a lack of proof of identify, and documented evidence for eligibility to work. Satisfactory evidence in conduct in previous employment (references) was only available on 1 of the 6 files, full employment history was available on 3 files. Satisfactory information about physical and mental health conditions relevant to the person's ability to work had not been obtained on 4 of the files. Another file had a health report that had been obtained 9 years earlier and another was from a former employer that had assessed the person as fit. Checks carried out by the Disclosure and Barring Service (DBS) were not available on file but were later shared with us for 5 staff. Following our site visit the practice applied for a DBS check for the 6th staff member and later shared the outcome with us. Satisfactory documentary evidence of relevant qualification and training was not available on the files sampled for 2 clinical staff. One clinician had since left employment. The provider told us it was reported that the clinician was up to date with training when commencing employment with them. They told us they would update their system when the staff member returned from annual leave. There was no record of staff immunisations on file. There was a discrepancy in the signatures of an employee on the records of 1 file we sampled, this was shared with the provider during our feedback.

The practice assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The practice had a designated infection, prevention and control (IPC) lead who was given protected time to undertake their role. The practice had adopted new guidance for completing infection control audits and for mitigating risks. The practice used an external cleaning company and cleaning schedules were in place and followed. The areas of the practice we viewed were visibly clean during our site visit and people we spoke with expressed no concerns relating to the cleanliness of the practice. We observed, and staff confirmed that they had access to adequate supplies of personal protective equipment. Staff could raise any issues relating to IPC during practice meetings held.

Refrigerators were used to store vaccines, and a cold chain policy was in place. No signage was on the plugs of 2 of the fridges to reduce the possibility of accidentally interrupting the electricity supply. A data logger was used to monitor the fridge temperatures, however, the data was only downloaded weekly. At the time of our site visit, whilst the fridge had an inbuilt thermometer in place, the practice relied solely on the data loggers for temperature monitoring. This meant that fridge temperatures were not monitored daily. Some historical data downloaded from the data loggers showed that there had been periods where the temperature had fallen outside of the manufacturer’s recommended temperature range. There was no documented evidence of actions taken to review these periods. No evidence of auditing could be provided either.

We reviewed a random sample of 5 medication reviews and found the medicines reviews were mostly of good standard. 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. Staff received regular training and were competency assessed on medicines optimisation.

Staff kept printer prescription stationary securely, logged serial numbers and no excessive stock was held. However, we found several prescription pads being stored in the drugs cupboard in case of emergency. Whilst the cupboard was locked, the serial number and auditing of these pads were not recorded or monitored for unaccounted prescriptions.

On the whole, staff followed protocols to ensure they prescribed all medicines safely, and ensured people received all recommended medicines reviews and monitoring. However, our clinical searches found 7 patients were overdue their monitoring for medicine to treat heart failure. We sampled 5 of the 7 patient records and found 5 patients were overdue their monitoring. Two of these patients had been contacted by the practice to attend for blood tests. The provider informed us following the inspection that all patients had been recalled. We identified 129 patients who were either on antiplatelet or an anti-inflammatory medicine without being prescribed a medicine to protect against gastrointestinal bleeding. The provider was asked to send us assurance of when the 129 patients would be reviewed.

Prescribing data reviewed as part of our assessment found the practice performance was in line with national averages for Pregabalin and Gabapentin medicines (primarily anticonvulsant drugs, also prescribed for pain); psychotropic medicines (used to treat various mental health conditions); hypnotic drugs (used for the management of severe insomnia); and antibiotics.