Royal Arsenal Medical Centre

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 assessed a total of 8 quality statements from this key question. We have combined the scores for these areas with scores based on the rating from the last inspection in 2018 which was rated good. Following this assessment, this key question is now rated as inadequate. We found multiple concerns regarding safe care and treatment. Risk assessments at the practice were not always in date and the practice had no infection prevention and control risk assessment. Systems in place to monitor patients who were prescribed certain medicines were not fully effective. There were gaps across several recruitment and training files. It was not evident if significant events were routinely discussed in staff meetings or if staff were clear on what defined a significant event.

This service scored 38 (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 did not have clear systems and processes in place to ensure learning from significant events and complaints was shared amongst the staff. For example, whilst we saw evidence that complaints were discussed in clinical meeting minutes, there did not appear to be any standard agenda items which included such headings. Therefore, we were not assured that significant events and complaints were routinely discussed or addressed in practice meetings. Additionally, it was not always clear what the complaint was about and what the specific learning needs which arose as a result were, so staff who were unable to attend meetings in person and who relied upon meeting minutes may not have been adequately informed about such events and subsequent learning needs identified. The practice held a significant event log; however, no significant events had been recorded since 2022. When speaking with senior leaders within the practice, there appeared to be some uncertainty regarding what the definition of this entailed, and inspectors were told that events which resulted in physical harm only would be recorded here. Therefore, we were not assured that the practice had full oversight of other potential significant events and missed learning opportunities. All staff we spoke with during this assessment stated they felt able to raise concerns. Many staff reported that senior management had an open-door policy and that staff were encouraged to speak up if they required further support.

The practice had systems in place to monitor patients who were referred on a 2 week wait pathway for suspected cancers, and had a dedicated team of administrative staff who would follow these patients up. During our remote clinical records searches, we identified some test results which had not been viewed in the clinical correspondence system, some dating back to July 2023. Whilst some clinical notes had not been viewed since 2023, we did not find any evidence of harm. However, the risk of these results not being reviewed in a timely manner meant that patients may not receive treatment or further monitoring tests.

All staff we spoke with during this assessment were able to detail what constituted a safeguarding concern, and who they would raise safeguarding concerns to. Staff we spoke with stated they would feel confident in raising concerns without delay. The practice held a safeguarding policy electronically which all staff reported they knew how to access. However, the safeguarding policy was not clear on roles and responsibilities within the practice. For example, in one section of the policy, the name of the deputy safeguarding lead was left blank, whereas elsewhere in the policy, the deputy safeguarding lead was named. The administrative safeguarding lead was named as one staff member, then as a different staff member in another section of the policy. There was a risk that inaccurate information may result in incorrect processes being followed, placing patients at potential risk of harm. Not all staff had received the appropriate level of safeguarding training applicable to their role. We reviewed 5 staff personnel files (3 clinical and 2 non-clinical staff members). One member of non-clinical staff had not received the appropriate level of children or adult safeguarding applicable to their role, and one clinical member of staff had not received the appropriate level of adult safeguarding training applicable to their role. Following our onsite assessment, we received evidence that these members of staff have since completed the missing training items. We were told there were 2 fire marshals at the practice; however, training had expired for 1 of the fire marshals. We were sent evidence that training had been booked for this staff member in February 2025.

During the onsite assessment, we spoke with 2 members of reception staff. Whilst they were able to detail some of the key signs to look for in a deteriorating patient, there were some concerns raised regarding the visibility of the waiting area. The reception desk offered poor visibility to 1 of the reception staff due to the height of the desk in one area. The desk was lowered where the other member of reception staff sat, which enabled a clear view of the reception area. We were advised that there were always 2 members of staff on duty in order to mitigate the issue with poor visibility. We observed there to be 2 members of staff on the reception desk during our onsite assessment. Three members of staff had not completed sepsis training. We were sent evidence that all 3 staff members had completed this training following our onsite assessment.

The practice premises appeared to be clean and in a good state of repair. The cleaning cupboard was kept in an orderly fashion, and the signed log from the cleaning contractors was appropriately signed. The reception areas and access to clinical rooms provided level access and adequate space for manoeuvring wheelchairs or pushchairs. The practice had expired certification for their Health and Safety, Legionella and Fire risk assessments. All of these certificates expired in November 2024. We saw evidence that these risk assessments had been booked to be completed in January 2025. The practice had an appropriate stock of emergency medicines that we would expect to find in a GP practice. We saw evidence that monthly checks were completed, with medicines approaching their use by dates highlighted. However, the defibrillator kept by the practice did not have any spare or paediatric pads available for use. Following the onsite assessment, we were provided with evidence to demonstrate these had been sourced and were now in situ. The location of the emergency medicines was in a locked room, off the main reception area. Some of the emergency medicines were stored in a locked cupboard within this room. We were advised the emergency medicines were kept in this way so patients could not readily access the area. When asked how these would be accessed quickly in the case of emergency, we were told that all reception and administrative staff knew where the key for this room was stored behind the reception desk. During the site visit, we spoke with 2 staff behind the reception desk, and both members of staff did not know where this particular key was located.

All staff spoken with during this assessment felt they were provided with adequate supervision and appraisal arrangements. Staff reported they felt they could approach senior management with any potential training needs, and these would usually be honoured. During our onsite assessment, we found a number of gaps in staff recruitment files. We reviewed 5 staff personnel files (3 clinical and 2 non-clinical staff members). Whilst a number of missing items were sent over following our assessment, some gaps remained; 2 clinical staff members had no record of references, and 1 non-clinical member of staff did not have a current Disclosure and Barring Services (DBS) check (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable).

The practice had an up-to-date infection prevention and control (IPC) policy which was stored electronically. All staff spoke with during this assessment knew how to access the policy; however, not all staff were aware of who the IPC lead for the practice was. This was not specified within the practice policy. The practice had adopted a number of IPC-related policies created by another NHS trust. Despite having a page on these policies to specify from what date these were implemented and when the review dates were, none of this information was completed. We saw no evidence of the practice having completed an IPC risk assessment. There was a risk that infection control risks had not been identified and subsequently mitigated, which placed patients at risk of harm. The practice had sent evidence of an externally completed IPC audit from July 2023. Despite a rating of 89% being awarded, we were not provided with evidence of an action plan following this audit. Additionally, we were not provided with any evidence of in-house IPC audits which had subsequently been completed. After our onsite assessment we were sent 3 audits for March, June and September 2024. These audits had identified some areas for improvement (for example, items to be stored off the floor, clinical chairs to be replaced), but it was unclear if any action had been taken. We were sent a clinical room curtain change log. The log said curtains were to be changed every 6 months, however the log showed some curtains were changed after 7, or 8 months, or not at all in the time period reviewed.

We reviewed 5 patients prescribed a medicine that increases the risk of internal bleeding. NICE guidelines states these patients should be prescribed a type of medicine that reduces this risk. We found all 5 patients had not been prescribed this medicine. We reviewed 5 patients with diabetes. We found 3 patients had not been recalled for repeat monitoring tests. Our clinical records searches identified gaps in the monitoring of patients with long-term medical conditions, such as asthma and hypothyroidism. The provider responded to say the call/recall system was disrupted between June-September 2024 due to a cyber attack. However, for some patients, there was no evidence the provider had identified the patient was overdue monitoring, in addition one patient’s monitoring tests were due in April 2024, pre-dating the cyber attack. The practice did not always alert patients to the risks associated with taking certain medicines. Our clinical records searches identified a number of patients who were prescribed a medicine which had potential significant side effects. Records failed to consistently identify that patients were informed of the potential side effects The practice did not always document sufficient information within patient clinical records. We sampled 5 patients who had received a medication review in the past 3 months, and found that all 5 of these patients had insufficient information contained within their electronic patient record to accompany the review. Additionally, 3 out of the 5 patient medication reviews we sampled were coded, but with no evidence of a medication review having been completed. We found evidence in 1 review where a patient was not compliant with a particular medicine, which had not been picked up during the medication review. The provider responded to say their medication reviews were not always completed with the patient. There was a risk that patients would not be involved in decisions about their prescribed medicines.