Earl's Court 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 has changed to requires improvement. The service was in breach of legal regulation in relation to safe care and treatment.

This service scored 62 (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 proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The service had effective systems to identify and learn from incidents. The service encouraged staff to report safety incidents and any incidents they considered to have learning potential. Staff told us they were encouraged to report incidents

The service had a system for recording and monitoring significant events and other types of incidents such as ‘near misses’ so learning could be shared across the whole team. Significant events were discussed at staff and clinical meetings.

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 reduced the risk of recurrence and improved safety.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored.

There were systems in place for processing information relating to people who were registering with the service. The service supported people moving across health and social care pathways.

Referrals and test results were managed in a timely way and allocated to the appropriate team member. There were systems to manage results when staff were on leave.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. The service maintained a list of vulnerable people and acted on concerns working in partnership with other organisations.

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.

Staff could recognise a deteriorating person and knew of action to take. Our records review showed that people were advised on risks related to their condition and actions to take if their condition deteriorated. Emergency equipment was available and maintained.

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

The service had improved its systems for identifying environmental risks, mitigating these and recording the action taken. They ensured that equipment, facilities and technology supported the delivery of safe care.

Health and safety risk assessments and audits had been undertaken, for example, a fire safety inspection had been completed in March 2025. Equipment calibration and portable appliance electrical safety testing was carried out annually. The managers took action to address concerns identified in the risk assessments although there had been a delay in actioning some recommendations from the fire safety risk assessment which required some changes to the premises to meet current regulations. We saw evidence showing that the service was in discussion with the landlord to progress these actions. There was a business continuity plan in place which was monitored and reviewed.

The service 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 in the service. We found training was up to date, learning needs and development of staff were managed appropriately, and staff were working in their agreed areas of competence. Safe recruitment practices were followed. The service carried out appropriate checks before people started work including DBS checks and evidence of satisfactory conduct in previous employment.

All the staff members we spoke with were positive about the staff team and the available clinical support and supervision including for those working at the service in associated roles whose work was funded by the primary care network. However, there was scope to introduce more structured clinical supervision slots and documentation of these, for example with non-medical prescribers and staff carrying out medicines reviews.

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 a designated infection, prevention and control lead and all staff had received relevant training. Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks.

The service did not ensure that medicines and treatments were prescribed safely.

The service did not have effective systems to manage and respond to national patient safety alerts and medicine recalls. We found one example of an alert which had not been effectively implemented for all affected people. In this case the alert recommended regular blood test monitoring for people prescribed a medicine used to block the action of the hormone aldosterone alongside certain medicines used to treat high blood pressure. This combination of medicines can lead to a build-up of potassium levels in the blood which can be unsafe.

We also found that medicines reviews did not always include sufficient detail, for example about the context of a consultation so that other practitioners would fully understand what had been reviewed and the outcome. Medicines reviews were not always completed when due, for example for people with diabetes.

Our searches identified some cases suggesting the service was not effectively managing prescribed certain medicines which can be dependency forming by not always actively encouraging a reduction in dose-levels over time. However, the service was overall prescribing these medicines at a lower rate than the national average.

We also found some other aspects of medicines management where the service had improved, for example, in its monitoring of people prescribed certain higher risk medicines and its management of people prescribed multiple medicines.

Staff who were qualified to prescribe were confident about their agreed scope of professional practice and had access to advice and supervision. Non-prescribing staff who were administering medicines were correctly authorised to do so.

Staff received regular training and updates on medicines optimisation. Staff were confident managing the storage, administration and recording of medicines. Prescription stationery was monitored appropriately and securely. Emergency medicines were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates of emergency medicines and vaccines. Medical gases, such as oxygen were stored and labelled safely.