Castlegate Derwent Surgery
Other
Action Taken
Castlegate & Derwent Surgery has implemented changes in leadership and governance following the ejection of a business manager and subsequent CQC inspections. A system for logging and managing significant events has been established, with clear processes for reporting, documentation, analysis, and learning dissemination. (AI summary)
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Response to Regulation 28 Report to Prevent Future Deaths 23/10/25 Matters of Concern:
1. Castlegate & Derwent Practice does not have unified leadership and governance.
2. Castlegate & Derwent Practice does not yet have a robust method of investigating incidents. Response:
1. Leadership and Governance Castlegate & Derwent Surgery has gone and continues to go through a very difficult and challenging time. Our former business manager was ejected from the practice in February 2023 due to fraud, misconduct and dereliction of duty. As a result of his misconduct and dereliction of duty the practice suffered crippling financial losses, which significantly threatened the ongoing viability of the practice. For 18 months we were unable to recruit a practice manager to replace the ejected manager and were without a practice manager until November 2024 when our now practice manager was appointed to the role. In the interim period, initially one partner worked in a management role, with this responsibility subsequently being shared with two other partners from November 2023. One partner ceased his management role in September 2024. Partners have continued to support the practice manager with management since their appointment. As a result of the dismissal of our former business manager, a CQC inspection was triggered in April 2023 which found the practice to require improvement in several domains and overall. A further CQC inspection took place in May 2024 which found the practice to be inadequate in the Well-led domain and to require improvement overall. A further full CQC inspection took place in January 2025 which saw an improvement in the Well-led domain from inadequate to requires improvement, but the practice was found still to require improvement overall. Following the CQC inspection in May 2024, on 9th August 2024 we were issued with a warning notice from the CQC for failure to comply with Regulation 17 (1) Safe care and treatment, of The Health and Social Care Act 2008 Regulations. This was namely in relation to failure to establish policies, systems, governance and processes which operate effectively to assess, monitor and improve the quality and safety of care provided in the carrying on of the regulated activities. The CQC also found a backlog of significant events, and that we were unable to demonstrate learning from significant events. They found that the management of significant events and complaints at the practice did not keep staff or service users safe. Under the management of our former business manager there was a lack of governance and assurance structures which presented a risk to patient care. It was also identified learning from significant events and complaints was not maximised.
We have subsequently worked very hard to address these failings. The new practice manager has worked closely with partners since appointment to ensure that robust governance and assurance systems are in place. This has included introducing a Governance Scheme of Delegation, reviewing the practice’s Organisational Structure, updating and improving the practice’s Risk Register, introducing a rolling programme of meetings, and taking ownership for the management of complaints. We have also worked closely with the CQC and the ICB in order to address these matters. Over the last 12 months, the practice manager has supported partners to ensure effective governance, assurance and auditing processes to assess, monitor and drive improvement in of the quality and safety of the service. The practice manager has supported partners in establishing and embedding systems and processes to monitor and mitigate risks in relation to health, safely and well being of patients. This now includes:
• Structured monthly Partners Governance Meetings with a clear agenda with standing items including; significant events, complaints, audit & risk, etc
• New Risk Register held on Practice Index and updated by all as new risks identified
• Regular monthly risk management meeting
• Regular monthly significant events meeting
• Regular safeguarding meetings
• Regular monthly complaints meeting These changes were in their infancy at the time of the CQC inspection in January 2025 but have now been fully embedded into the operational management of the practice over the last 12 months and all of the practice is now engaged with the new governance processes. The CQC Inspector has been meeting regularly with the practice manager since the Inspection Report was published to review ongoing progress, and evidence has been shared to support compliance. Whilst governance aspects are now working well, unfortunately there is an ongoing partnership dispute. One partner has accused the others of breaching the partnership agreement and of colluding with the former business manager. In January 2025 there were seven partners, there are currently five remaining. The dispute continues, and these allegations have resulted in the resignation of all other remaining partners. Two previous partners have already left, and those who have given notice have planned departure dates over the coming year. This is an extremely challenging situation and poses a significant risk to the practice. It appears unlikely that the dispute will be resolved, as the partner raising the allegations has not engaged in the external mediation process that was initiated in the summer and a subsequent mediation process that is currently in progress. Whilst this continues, it will be difficult for the practice to maintain unified leadership. However, unified governance processes remain in place as described above, all partners are engaging in the updated structures and processes, and there is a strong management team of four managers in place. We are working hard to mitigate the risk posed by the above situation in order to ensure the continued safe running of the practice. We are in the process of approaching other organisations with a view to merger or takeover of the practice. We are also actively recruiting GPs and other clinicians to support with the current and upcoming vacancies.
2. Method of investigating incidents The processes and procedures for managing significant events and investigating incidents are very different now as to how they were in early 2024. At the time of Dr Foster’s death, our significant events process was managed by one of the partners. It was found by the CQC that this process was inadequate and did not meet the expected standards. Staff involved in the significant event process were not trained, the practice was not registered with the correct national reporting systems and partners were not aware of their CQC reporting responsibilities. In September 2024 as result of the warning notice issued by CQC in August 2024 a new significant events process was implemented under the management of a very experienced salaried GP. We now have in place a robust system for the management of significant events to maximise learning from these. All practice staff have now been enrolled on significant event training. The GP who leads on significant events has trained management, administrative and IT infrastructure support. In particular, the appointed GP has been tasked to establish and share learning practice wide. The practice is now also using LFPSE (Learn from patient safety events) service to report events externally. This prompts consideration of onward reporting to other external agencies such as the CQC. The System for logging and managing significant events is detailed below:
• All staff have been instructed to report significant events on the NHS ‘Record patient safety events’ website
• All staff then report the significant event to the appointed GP
• Staff log the event on the “learning from patient safety events” (LFPSE) portal from NHSE.
• Significant events are anonymously documented on the Practice Index Platform by the appointed GP
• Any actions required from the significant event are recorded on Practice Index and allocated to the relevant member of staff
• All documentation, correspondence and related paperwork is scanned and stored on the surgery’s server in a protected folder
• All hard copy documentation is filed and stored
• Significant Events will be analysed on a monthly basis by the appointed GP with trends identified for further investigation
• Learning from significant events will be discussed at morning multi-disciplinary teams meetings, monthly significant event meetings and at Partner Governance Meetings
• Learning from significant events is now shared (where appropriate) in the weekly Staff Briefing Communication which is emailed to all surgery staff to foster improvement to patient care
• An open, inclusive and learning culture will be adopted to ensure that there is a ‘no blame culture’ in relation to significant events and staff feel supported throughout the process. The CQC saw evidence at their last inspection in May 2025 that significant events were now being reported appropriately and that all staff were given the opportunity to attend significant events meetings, with the expectation of one person from each department attending as a
minimum. Processes to share learning from significant events were still being embedded at that time but are now firmly in place. Please also find attached our new practice “Quick guide to Significant Events” flow chart. 17th December 2025
1. Castlegate & Derwent Practice does not have unified leadership and governance.
2. Castlegate & Derwent Practice does not yet have a robust method of investigating incidents. Response:
1. Leadership and Governance Castlegate & Derwent Surgery has gone and continues to go through a very difficult and challenging time. Our former business manager was ejected from the practice in February 2023 due to fraud, misconduct and dereliction of duty. As a result of his misconduct and dereliction of duty the practice suffered crippling financial losses, which significantly threatened the ongoing viability of the practice. For 18 months we were unable to recruit a practice manager to replace the ejected manager and were without a practice manager until November 2024 when our now practice manager was appointed to the role. In the interim period, initially one partner worked in a management role, with this responsibility subsequently being shared with two other partners from November 2023. One partner ceased his management role in September 2024. Partners have continued to support the practice manager with management since their appointment. As a result of the dismissal of our former business manager, a CQC inspection was triggered in April 2023 which found the practice to require improvement in several domains and overall. A further CQC inspection took place in May 2024 which found the practice to be inadequate in the Well-led domain and to require improvement overall. A further full CQC inspection took place in January 2025 which saw an improvement in the Well-led domain from inadequate to requires improvement, but the practice was found still to require improvement overall. Following the CQC inspection in May 2024, on 9th August 2024 we were issued with a warning notice from the CQC for failure to comply with Regulation 17 (1) Safe care and treatment, of The Health and Social Care Act 2008 Regulations. This was namely in relation to failure to establish policies, systems, governance and processes which operate effectively to assess, monitor and improve the quality and safety of care provided in the carrying on of the regulated activities. The CQC also found a backlog of significant events, and that we were unable to demonstrate learning from significant events. They found that the management of significant events and complaints at the practice did not keep staff or service users safe. Under the management of our former business manager there was a lack of governance and assurance structures which presented a risk to patient care. It was also identified learning from significant events and complaints was not maximised.
We have subsequently worked very hard to address these failings. The new practice manager has worked closely with partners since appointment to ensure that robust governance and assurance systems are in place. This has included introducing a Governance Scheme of Delegation, reviewing the practice’s Organisational Structure, updating and improving the practice’s Risk Register, introducing a rolling programme of meetings, and taking ownership for the management of complaints. We have also worked closely with the CQC and the ICB in order to address these matters. Over the last 12 months, the practice manager has supported partners to ensure effective governance, assurance and auditing processes to assess, monitor and drive improvement in of the quality and safety of the service. The practice manager has supported partners in establishing and embedding systems and processes to monitor and mitigate risks in relation to health, safely and well being of patients. This now includes:
• Structured monthly Partners Governance Meetings with a clear agenda with standing items including; significant events, complaints, audit & risk, etc
• New Risk Register held on Practice Index and updated by all as new risks identified
• Regular monthly risk management meeting
• Regular monthly significant events meeting
• Regular safeguarding meetings
• Regular monthly complaints meeting These changes were in their infancy at the time of the CQC inspection in January 2025 but have now been fully embedded into the operational management of the practice over the last 12 months and all of the practice is now engaged with the new governance processes. The CQC Inspector has been meeting regularly with the practice manager since the Inspection Report was published to review ongoing progress, and evidence has been shared to support compliance. Whilst governance aspects are now working well, unfortunately there is an ongoing partnership dispute. One partner has accused the others of breaching the partnership agreement and of colluding with the former business manager. In January 2025 there were seven partners, there are currently five remaining. The dispute continues, and these allegations have resulted in the resignation of all other remaining partners. Two previous partners have already left, and those who have given notice have planned departure dates over the coming year. This is an extremely challenging situation and poses a significant risk to the practice. It appears unlikely that the dispute will be resolved, as the partner raising the allegations has not engaged in the external mediation process that was initiated in the summer and a subsequent mediation process that is currently in progress. Whilst this continues, it will be difficult for the practice to maintain unified leadership. However, unified governance processes remain in place as described above, all partners are engaging in the updated structures and processes, and there is a strong management team of four managers in place. We are working hard to mitigate the risk posed by the above situation in order to ensure the continued safe running of the practice. We are in the process of approaching other organisations with a view to merger or takeover of the practice. We are also actively recruiting GPs and other clinicians to support with the current and upcoming vacancies.
2. Method of investigating incidents The processes and procedures for managing significant events and investigating incidents are very different now as to how they were in early 2024. At the time of Dr Foster’s death, our significant events process was managed by one of the partners. It was found by the CQC that this process was inadequate and did not meet the expected standards. Staff involved in the significant event process were not trained, the practice was not registered with the correct national reporting systems and partners were not aware of their CQC reporting responsibilities. In September 2024 as result of the warning notice issued by CQC in August 2024 a new significant events process was implemented under the management of a very experienced salaried GP. We now have in place a robust system for the management of significant events to maximise learning from these. All practice staff have now been enrolled on significant event training. The GP who leads on significant events has trained management, administrative and IT infrastructure support. In particular, the appointed GP has been tasked to establish and share learning practice wide. The practice is now also using LFPSE (Learn from patient safety events) service to report events externally. This prompts consideration of onward reporting to other external agencies such as the CQC. The System for logging and managing significant events is detailed below:
• All staff have been instructed to report significant events on the NHS ‘Record patient safety events’ website
• All staff then report the significant event to the appointed GP
• Staff log the event on the “learning from patient safety events” (LFPSE) portal from NHSE.
• Significant events are anonymously documented on the Practice Index Platform by the appointed GP
• Any actions required from the significant event are recorded on Practice Index and allocated to the relevant member of staff
• All documentation, correspondence and related paperwork is scanned and stored on the surgery’s server in a protected folder
• All hard copy documentation is filed and stored
• Significant Events will be analysed on a monthly basis by the appointed GP with trends identified for further investigation
• Learning from significant events will be discussed at morning multi-disciplinary teams meetings, monthly significant event meetings and at Partner Governance Meetings
• Learning from significant events is now shared (where appropriate) in the weekly Staff Briefing Communication which is emailed to all surgery staff to foster improvement to patient care
• An open, inclusive and learning culture will be adopted to ensure that there is a ‘no blame culture’ in relation to significant events and staff feel supported throughout the process. The CQC saw evidence at their last inspection in May 2025 that significant events were now being reported appropriately and that all staff were given the opportunity to attend significant events meetings, with the expectation of one person from each department attending as a
minimum. Processes to share learning from significant events were still being embedded at that time but are now firmly in place. Please also find attached our new practice “Quick guide to Significant Events” flow chart. 17th December 2025