Archived: Eltham Palace Surgery

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• 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 Requires improvement. At this assessment, the rating remains the same.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

The practice did not have consistently effective systems to manage test results in a timely manner. The practice had implemented a GP buddy system, and we saw evidence of a document which set out this process; however it was not used consistently by all staff members.

At our last assessment in February 2025, clinicians reported that they had excessive numbers of results to review, which posed a potential risk to patient safety, due to the length of time taken to review results and, if appropriate, begin treatment. At this assessment, one of the GP partners reported that results were allocated to them for tests that they did not request. The practice attempted to improve the time in which test results were reviewed by giving clinicians administration time for the task. However, we found that a number of test results had not been checked and remained unfiled, some of which had been received by the practice 2 weeks earlier, and which could have potentially contained results requiring further investigation. Therefore, patients were placed at risk due to the additional time take to review results and, where appropriate, begin treatment.

The practice reported that they did not routinely take action if a child was not brought to an appointment. We identified a child who was not brought to an appointment scheduled to review their long-term condition. From this child’s clinical record it was evident the child’s long term condition was not well managed and the current management plan was not effective. There was no evidence the missed appointment was flagged and reviewed and no plan to reschedule the appointment.

The practice had systems in place to monitor patients who were referred for urgent assessment of suspected cancer symptoms.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

The service did not always make sure equipment, facilities and technology supported the delivery of safe care.

The practice is located in a premises shared with a number of other services. At our last assessment in February 2025 we found that emergency medicines were located in a clinic room not routinely used by the practice. At this assessment, the practice had moved the stock of the emergency medicines to a more accessible location. However, we noted that spare adult defibrillator pads were not available. The practice ordered spare defibrillator pads during our visit and subsequently sent evidence showing them in place.

At our previous assessment in February 2025, we found out of date items in clinical rooms. At this assessment, we did not find any out of date items. There was a robust system in place to manage the monitoring of emergency medicines and expiry dates of equipment and vaccines.

Health and safety risk assessments and audits had been undertaken and risks identified had been addressed. There was a business continuity plan in place which was monitored and reviewed.

At our inspection in February 2025, the practice reported some issues regarding retention of recently employed staff members (in particular, those in non-clinical roles). At this assessment, staff told us of continued issues to recruit and retain staff. The practice told us that two reception/administrative staff, one healthcare assistant/care-co-ordinator and a pharmacy technician had been recruited and were due to start at the practice the following week.

The practice stated that they had introduced a competency list for reception staff, to ensure consistency of work as new staff were trained.

Patients and staff were positive about improved access to appointments over the past year.

There were a range of clinical and non-clinical roles within the practice. We found training was up to date, and safe recruitment practices were followed.

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

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

When we assessed the practice in April 2024 we found issues with the management of medicines. When we last assessed the practice in February 2025, we found that patients’ medicines were managed in line with national guidance.

The service did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

The provider’s systems to manage and respond to safety alerts and medicine recalls were not consistently effective. We identified two patients who were prescribed a medicine which posed additional risks because of the patients’ age. Based on the evidence in the clinical records, the patients had not been advised of these risks. We looked at the records of 5 patients prescribed a medicine that can cause harm to a developing foetus if taken during pregnancy. Based on the evidence in the clinical records, the provider had not followed national guidance to ensure pregnancy prevention programmes were followed.

We looked at the records of patients on a medicine that needs to be overseen by a hospital consultant. Some patients did not have a record of this shared care being agreed. This medicine needs to be taken once a week, on a specified day. This information was not always included on the prescription

The provider’s systems to ensure that people prescribed medicines with specific risks received the recommended monitoring were not consistently effective. Based on the evidence we saw in clinical records, if patients did not respond to one means of communication (e.g. phone calls) practice protocols did not ensure that staff would try a different method.  

Out of 223 patients prescribed 1 medicine that requires specific monitoring, 10 had not received the required monitoring in the preceding 18 months. We looked at the records of 4 of these patients and found inconsistent recall for monitoring in line with national guidelines.

We looked at records of patients experiencing an exacerbation of asthma. There was not enough detail in the clinical record to show a clinical justification for the prescribing in 3 of 5 records we reviewed.

On the day of our remote clinical records searches (26 January 2026), we found the electronic correspondence system used by the practice showed 213 unfiled results (122 of which were abnormal), dating back to 12 January 2026. There was risk to patient safety as this could have contained information requiring urgent action, thus causing a significant delay to further treatment or investigation.

Medicines prescribed in a hospital setting were not always added to patients’ records. This placed patients at risk of harm as clinicians may not be aware of all the medicines a patient was taking when prescribing.

There was no clear process for the supervision of salaried doctors, locum doctors, or pharmacists.