Stopsley Village Practice

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

This means we looked for evidence there was a culture of openness in which there was a willingness to identify and learn from safety events. We looked for evidence people were protected from abuse and avoidable harm.

At our last inspection we rated this key question Good.

At this inspection, the rating has changed to Requires Improvement.

This is because the practice did not always provide care in a way that kept patients safe and protected from avoidable harm.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff told us they would report concerns, safety incidents and near misses through a variety of different ways.

The practice had recorded 6 significant events in the year leading up to this inspection. The practice had also recorded 4 accidents in the accident book and had completed a hazard reporting record for another event.

Although these systems were in place, they did not always work effectively to make sure learning from them was maximised and shared with staff.

While leaders had taken actions in response to some accidents, such as installing a concrete step at one of the fire exits from the practice, other accident reports lacked detail.

While a variety of staff gave an example of a significant event that had affected the practice and told us learning events were discussed in team meetings, the practice did not provide evidence all significant events and accidents had been discussed in staff meetings.

However, in addition, the practice provided minutes of a staff meeting held in April 2024 where a significant event had been discussed. However, the practice did not provide records this had been recorded as an accident or significant event.

There were no records of an incident that happened in the year leading up to this inspection where the Police had been called. We did not see evidence the practice had recognised this as a learning opportunity or identified any learning from it. There was no evidence showing how the practice had responded to the incident or that learning was shared with staff to improve patient and staff safety.

Over the 2 years leading to this inspection, other services that worked with Stopsley Village Practice told us they felt the practice did not always respond fully to feedback given. They told us they were not satisfied the practice had taken reasonable steps to minimise risks and prevent concerns happening again. These other services told us they were not confident the provider always recognised when incidents occurred, fully investigated them and had the ability to identify and implement any learning from them.

The practice had a system for recording and acting on safety alerts received into the practice, such as those from the Medicines and Healthcare Products Regulatory Agency (MHRA). However, this system did not work effectively to make sure actions from them were embedded into routine practice, patients affected by them were always identified and actions taken to protect them from avoidable harm.

We ran a search of the practice’s clinical records system to identify patients who were affected by a safety alert about prescribing Citalopram and Escitalopram, medicines used to help people experiencing low mood or depression. We identified 3 patients who were prescribed doses of these medicines that were higher than the dose recommended in the safety alerts. We did not see evidence these 3 patients had been made aware of the risks. The practice had not documented the reasons for prescribing the medicines in these ways, including when this differed from advice given by a specialist doctor. The practice had already booked to review the medicines with 1 of the patients. In response to our feedback, the practice told us they would contact all 3 patients.

The practice also told us they had identified a patient who had been affected by a safety alert from MHRA about taking the medicines Simvastatin and Amlodipine at the same time. In response to this incidental finding, the practice ran a search of the clinical records system and identified another 18 patients prescribed this medicine combination. The medicine combination had been recently started for one of the patients. The practice told us they had contacted 18 of these 19 patients to book reviews of their medicines.

However, the practice did not tell us how they planned to improve their system to make sure all patients affected by safety alerts would be protected from harm.

People who provided feedback for this inspection told us the practice referred them to other services when needed in a timely manner.

Staff had the information they needed to deliver safe care and treatment.

There was a system for processing information relating to new patients including the summarising of new patient notes.

Leaders were aware, however, there was a backlog in summarising historic patient records. They told us they had investigated ways to help complete this work.

Although the records awaiting summarising were kept in an organised way, they were at risk of damage as they were not kept in a container that would help protect them, for example from fire or water.

Partners, for example the care home to which Stopsley Village Practice is aligned, told us the practice was responsive and staff were willing to refer residents to other services when needed and did so in a timely manner.

Care home staff told us the practice registered new residents promptly. This was important because the practice supported people who were discharged from hospital to the care home, which included those nearing the end of their lives.

Referrals to specialist services were documented, contained the required information and there was a system to monitor delays in referrals.

Our search of the practice’s clinical records system showed referrals were sent and letters and test results coming into the practice were processed in a timely way.

Staff knew who the lead for safeguarding was, and knew how to make referrals to local safeguarding teams.

Staff knew where to find information about safeguarding, such as practice policies, and information was displayed on noticeboards in all clinical rooms.

While leaders told us the practice ran a search of their clinical system monthly to identify patients for whom there were, or may be, safeguarding concerns, and that they discussed adults for whom there were safeguarding concerns at monthly multi-disciplinary meetings, the minutes of these meetings did not show safeguarding concerns had been routinely discussed since April 2024 and we did not see evidence of the monthly searches described by leaders.

There were no longer regular meetings to discuss children for whom there were, or could be, safeguarding concerns.

However, the practice’s safeguarding lead attended meetings about specific children and adults when appropriate.

External services told us about support they had given to the practice to help them identify areas for improvement and maximise learning from serious incidents and concerns that had happened in the 2 years leading up to this inspection, including those relating to safeguarding.

Disclosure and Barring Service (DBS) checks identify whether a person has a criminal record or is on an official list of people that should not work in roles where they can have contact with children or adults that can be made vulnerable. These checks help to protect other staff and people that use the service from abuse.

There was no evidence the practice had checked an appropriate and satisfactory DBS check had been carried out for all staff. This included staff who had started working at the practice in the 2 years leading up to this inspection as well as clinical staff who were employed through locum agencies or the Primary Care Network (PCN) Stopsley Village Practice had joined in April 2024. A PCN is a group of practices working together to address local priorities in patient care. This meant the practice could not be sure the members of staff were suitable for their roles from when they began working at the practice.

This also included staff who acted as chaperones. A chaperone is an impartial observer present during an examination or consultation when a patient may feel vulnerable, for example during an intimate examination. A chaperone acts to protect both patients and staff.

Following our feedback, leaders gave us copies of risk assessments they had completed for some members of staff to help identify and manage risks in the absence of DBS checks.

The practice’s policies were not clear about what training staff were required to complete in safeguarding children and in safeguarding adults. We found not all staff had completed training in line with national guidance.

The practice had reviewed most of the policies provided for this inspection in January 2024. However, information in some of the policies required updating and the contact details for relevant people and organisations adding.

People were informed about any risks and how to keep themselves safe, including what to do and who to contact if their condition did not improve or if they experienced any unexpected symptoms.

Sepsis, sometimes called blood poisoning, happens when the 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.

Although most clinical and non-clinical staff told us they had completed training in sepsis awareness, and receptionists were aware of actions to take if they encountered a deteriorating or acutely unwell patient, awareness about sepsis should be improved.



The provider did not have oversight of this training and did not provide evidence of this training staff said they had completed. However, the provider told us 15 out of the 18 non-clinical members of staff and 7 of the 21 members of clinical staff had completed training in sepsis awareness following our feedback.

The practice held appropriate emergency medicines.

There was a system was in place to monitor the expiry dates of emergency medicines and equipment. During our site visit, we found emergency medicines to be in date.

The practice kept medical oxygen and a defibrillator on site, and there were systems to ensure these were regularly checked and fit for use.

However, the way the practice recorded these checks could be strengthened. For example:

• To show what checks had been made and whether they were satisfactory.

• To record how many of each item or medicine were available.

Staff were aware of the procedure for emergency evacuation, for example in the event of fire.

Most staff knew who the fire marshals and wardens were for the practice.

The practice had responded to some of the actions identified in the practice’s most recent fire risk assessment, completed by an external company on 8 October 2024. Leaders told us they were taking steps to respond to other recommendations.

Members of staff were named as fire marshals and wardens in this risk assessment, however, these staff members told us they did not carry those roles.

During our site visit, we saw various fire extinguishers throughout the building, which had been serviced appropriately.

However, there were some inaccuracies in the recording of weekly fire alarm tests.

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 to ensure patients receive appropriate treatment. During our site visit, we saw most equipment had been tested in February 2024.

The practice shared with us their Fire Evacuation Plan. While this document was not dated it required updating. For example, the information about alerting the Fire and Rescue Service and the names of the fire marshals.

Staff had completed training in fire safety. However, we did not see evidence staff who were fire wardens or marshals had completed additional training to enable them to do the role safely.

Leaders provided 2 records of a fire drill carried out in April 2024.

We received feedback from patients that there were not so many appointments with the practice’s regular GPs now and that there was a reliance on locum staff. People told us this has impacted on continuity of care.

Staff told us they felt there were enough staff to provide appointments and prevent staff from working excessive hours.

There was an effective approach to managing staff absences and busy periods. For example, the practice had identified more time for processing urgent requests for prescriptions for medicines were needed on Friday afternoons and before bank holidays. Leaders recognised the changing pressures on the practice and told us they made adjustments when needed, for example making sure suitable appointments were available for minor illnesses when the increase in demand was expected, such as during the winter.

We looked at the staff files for 2 clinical and 2 non-clinical members of staff who had started working at the practice in the 2 years leading up to this inspection. We found the practice had not always completed recruitment checks in line with regulations and the practice’s policies. For example:

• The practice’s policy said the practice should receive 2 satisfactory references for each new member of staff before they started working at the practice. We saw the practice had received 1 reference for each of the non-clinical members of staff and both references for the 2 clinical members of staff after they had started working at the practice. None of the files for these 4 members of staff contained a risk assessment. However, following our feedback, leaders provided risk assessments for all 4 members of staff dated with the date the member of staff began working at Stopsley Village Practice.

• There were gaps in the employment histories for all 4 members of staff. Following our feedback, leaders provided documents showing the gaps had been explored during the recruitment interviews for 2 of the members of staff.

• For one of the clinical members of staff, leaders had received evidence of the person’s qualifications after the member of staff had started working at the practice. We did not see a risk assessment in the file for this member of staff.

Although staff told us they felt comfortable asking for help, and support and advice was available when they needed it, on a day-to-day basis, we did not see evidence the practice gave all staff more formal supervision, reviews and appraisals. For example:

• There was no evidence an appraisal had been completed with 11 of the 21 members of clinical staff.

• We looked at the staff files for 3 members of clinical staff who worked in enhanced practitioner roles, such as nurses and physician associates. For 2 of these members of staff, we saw evidence of occasional performance management meetings. However, the practice did not show us there was a system to demonstrate how they routinely sought assurances about the competence of these staff, for example through regular clinical supervision or review.

• There was no evidence the practice had made checks to make sure 2 of these members of staff had the required qualifications and professional registrations for their roles.

• Two of these members of staff were non-medical prescribers. A non-medical prescriber is a registered healthcare professional who has completed training to be able to prescribe certain medicines without needing to ask a doctor. Although there was evidence of infrequent monitoring and audits of the prescribing practices for one of these members of staff, the practice could not provide evidence of the prescribing competence for the other member of staff.

The practice was a GP teaching and training practice and, at the time of our inspection, 2 GP trainers were supporting 4 GP registrars. Registrars are qualified doctors who are training to become GPs.

The provider told us the GP registrars always had access to support from a qualified GP. However, they also told us this was sometimes from a GP who was not an accredited trainer, but that they sought feedback from GP trainees about the support they had received when this had happened.

People who use the service told us they always found the practice to be clean and tidy.

Staff and leaders were aware the practice required some redecoration and updating.

Staff knew who the leads for infection prevention and control (IPC) were.

Training records the practice provided after our site visit showed non-clinical staff had completed training in IPC. However, the practice did not provide records for 3 of the 21 clinical members of staff and no dates had been recorded for a further 2 members of staff for whom the records showed training was due. The training records provided did not always say what training staff had completed. Therefore, we did not know if 4 of the clinical members of staff had completed appropriate training.

We observed the practice to be clean and tidy.

Various IPC audits had been completed by a variety of clinical and non-clinical members of staff. The most recent audits had been completed between May and August 2024.

However, these did not always identify risks, which meant the practice had not always taken action to reduce risks to patients, staff and others. For example, to improve safety of the disposal of sharps used to administer certain types of medicines. The practice responded immediately to our feedback to make sure suitable sharps bins were available in the practice.

The practice did not have a system for making sure staff had been vaccinated against infectious diseases in line with guidance from the UK Health Security Agency (UKHSA). Staff vaccinations help to protect staff, patients, visitors and the public from harm.

We looked at the staff files for 9 members of staff and found records of vaccination or immunity status were incomplete for 7 of the staff members. There were no associated risk assessments in the staff files to show how any risks would be managed. Following our feedback, leaders provided ‘Staff Vaccination Self Certification’ forms for some staff members. However, these did not include all recommended vaccinations, were not always fully completed and had not been signed by the staff members to confirm the declarations were accurate.

People told us staff who completed medicines reviews with them had been helpful and that they had felt listened to.

However, people told us most medicines reviews were carried out by telephone and that they would prefer to have better access to face-to-face appointments for medicines reviews.

People also told us about delays in repeat prescriptions being sent to a pharmacy so that the patient could collect their medicines in a timely way.

The practice ensured medicines were stored safely and securely with access restricted to authorised staff.

The practice had systems for monitoring the use of prescription stationery. However, blank prescriptions could be kept more securely, in line with national guidance.

The practice’s processes for ensuring staff had the appropriate authorisations to administer medicines, including Patient Group Directions (PGDs) and Patient Specific Directions (PSDs) needed strengthening. 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.

Some medicines, for example vaccines, need to be stored in a fridge to make sure they remain safe and effective to use. It is important to monitor the temperatures of the fridges to identify if the temperatures fall outside the acceptable range so that actions can be taken to make sure the medicines remain safe and effective to use.

Although leaders described the arrangements in place for daily checks of the fridge temperatures, they did not demonstrate these arrangements were reliable. For example:

• Out-of-range manual readings were not always identified and investigated so that, if needed, action could be taken in a timely manner to make sure the medicines stored in the fridge remained safe and effective to use.

• The practice did not regularly cross-check manual fridge temperature readings with readings from the data logger or second thermometer in the fridges. The practice had not identified and investigated occasions when temperatures recorded by these two systems did not match, including times when the cold chain may not have been maintained.

The practice completed medicines reviews for patients who were prescribed medicines on repeat prescription. However, of the sample of medicines reviews we looked at, we found the reviews were not always effective. For example, reviews did not always identify when a patient was overdue necessary monitoring or include all medicines prescribed. Possible concerns were not always identified or addressed, such as whether a patient was taking their medicines correctly and understood how to use the medicines prescribed for them.

Our search of the practice’s clinical records system identified 40 patients who had been prescribed benzodiazepine medicines or ‘Z drugs’ 10 or more times in the last year. These medicines need to be used carefully because a person’s body can change to tolerate them, creating a dependency on the medicine, and are known to be widely used illegally as a drug of abuse. We looked at the records for 5 of these 40 patients. We found:

• No evidence 1 of the patients had been made aware of the risks of taking the medicine.

• Although the practice told us they supported patients to reduce their use of these medicines using an holistic approach, for all 5 of the patients whose records we looked at, there was no evidence the practice had made recent attempts to help the patient reduce their use of these medicines.

• Although all 5 patients had had a review of their medicines in the last year, the amount of medicine issued for 2 of the patients was not in line with what would be expected if the patient was taking the medicine as prescribed. However, for another 2 of the patients, we saw the practice had limited the amount of medicine they issued.

There was a process for monitoring patients’ health in relation to the use of medicines that require monitoring. Most patients prescribed high-risk medicines had received the necessary monitoring to make sure it was safe to continue to prescribe the medicine and the dose prescribed was suitable. This specific and regular monitoring is needed because of the risks associated with taking the medicines. We found:

• 36 of the 37 patients prescribed Methotrexate or Azathioprine had been monitored in line with national guidance. These are medicines used to calm and control the body’s immune system, to stop or slow the disease process in inflammatory conditions, such as rheumatoid arthritis. For the other patient, the monitoring was overdue. However, the practice had attempted to contact the patient on several occasions. The provider described how they made sure medicines are prescribed safely for patients who do not attend for the required monitoring, including contacting the patient’s hospital specialist to discuss the shared care arrangements.

• Of the 184 patients who were prescribed a direct acting oral anticoagulant (DOAC) medicine, our search identified 17 (9%) patients had not been monitored in line with guidance. These medicines are used to help prevent blood clots forming in people who are at high risk of developing them. Blood clots can lead to serious conditions such as strokes and heart attacks.

• We looked at the records for 5 of these 17 patients. The practice had checked if the required monitoring was up-to-date before issuing repeat prescriptions for 1 of the patients. The date the monitoring was next due had been added to the repeat prescription forms for 2 of the other patients. However, this system had not worked effectively to make sure the monitoring was kept up-to-date. For one of the patients, the overdue monitoring had not been identified during a review of their medicines. The practice had already asked 2 of the patients to book an appointment to have the required monitoring. In response to our feedback, the practice told us they would review the processes they had in place, including the roles of the practice’s prescription clerks.