Archived: Eltham Palace 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 inspection, we rated this key question as Requires Improvement. At this inspection, the rating has remained the same.

We found significant events were investigated, and learning from significant events was shared with staff. We found arrangements for managing test results when clinicians were absent or on leave were unclear. There was a lack of documented communication with cleaning staff. Emergency medicines were placed in cupboards within the clinic room which were not always easily accessible to practice staff. The location of these medicines had not been risk assessed by the provider, despite some staff members reporting they had raised concerns regarding their location. Arrangements for monitoring and documenting fridge temperatures when nursing staff were on leave were unclear.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

At our previous inspection in March 2024, we were not assured that all staff attended meetings or had access to meeting minutes where significant events, patient safety alerts, complaints and safeguarding concerns were discussed. There was a link on the practice’s website directing patients to a complaint form; however, this did not work at the time of the assessment in March 2024.

At this inspection we found improvements had been made. Staff told us they attended meetings where learning events were discussed, and we saw evidence of these discussions in meeting minutes. Patients were able to make complaints using the link on the practice website, or by contacting the practice manager via telephone or in person.

The practice had systems in place to monitor patients who were referred on a 2-week wait pathway for suspected cancers.

There were systems in place for the processing of test results. Usually test results would be reviewed by the requesting clinician. However, some staff members had raised concerns about the reviewing of test results requested by clinicians who were on leave, or by locums who may not be in clinic when the test results became available. Clinicians reported 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.

The provider had a policy outlining cover arrangements for when a clinician was on leave. However, clinicians reported concerns about the number of test results to be reviewed when other clinicians, including the GP partners, were on leave. Therefore the processes outlined in this policy did not appear to be effective.

Following our inspection, the provider told us they planned to implement a GP buddy system to ensure test results were reviewed in the absence of clinicians. The provider also planned to introduce a system that would automatically identify and file normal patients results, reducing clinical admin time.

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.

At our previous inspection in March 2024, we found 10 boxes of physical patient records awaiting summarising. This had been identified as a fire risk but not addressed. At this inspection in February 2025, we found the provider had addressed this risk and there were now only a small number of documents requiring summarising.

At our previous inspection in March 2024, we found a number of items in clinical rooms to be out of date. At this inspection in February 2025, we again found several items in clinical rooms to be out of date; for example an anaphylaxis kit, ear thermometer probe covers and 2 pairs of single-use scissors. These were removed immediately by practice staff. There were records showing emergency equipment was checked regularly; however, these checks had not identified the out of date items.

The practice held medicines and equipment to enable response to medical emergencies. However, the practice did not hold a spare pair of adult defibrillator pads. Following our feedback to staff, we saw evidence the provider had purchased a spare pair of adult defibrillator pads. We found the emergency medicines were placed in cupboards within the clinic room. The premises used by the practice was shared with a number of other services and the emergency medicines were located in a clinic room not routinely used by the practice. Two separate keys were required to access the emergency stock. The provider had not risk assessed the suitability of the location of the emergency medicines, despite some staff members informing us they had raised concerns regarding their location to the GP partners. A recent incident had been reported where emergency medicines were required. Practice staff had to interrupt the consultation of a patient to enable access to the room containing the emergency medicines. This had resulted in a delay in the treatment of the affected patient. The location of the medicines may result in future delays to patients receiving treatment in an emergency, which placed patients at potential risk of harm.

Following our inspection, the provider told us they had carried out a risk assessment and updated the emergency protocols. The provider told us emergency equipment had been moved to a central location which was clearly signposted.

At our previous inspection in March 2024, the practice had an action plan for staff recruitment, which included the recruitment of additional reception staff, a reception manager and a deputy to the business manager. At this inspection in February 2025, we saw evidence that recruitment had taken place, although some staff had also left the practice. We were informed by staff that an operations manager was in post and additional reception staff had been recruited (but had not yet commenced work in the practice). We were told by staff at the practice that the poor relationship between the partners had impacted the provider’s ability to recruit and retain staff. We saw evidence of communication between leaders at the practice where disagreements about recruitment had resulted in the provider’s inability to recruit a reception manager. The provider had not adhered to the practice’s own guidance for recruitment. This post was yet to be filled at the time of our inspection in February 2025.

The provider had recruited a salaried GP to work 4 sessions per week who was due to commence work in the practice in March 2025. We were told there remained a vacant salaried GP role to provide 4 sessions per week; at the time of our inspection these sessions were being filled by locum GPs.

Feedback from patients and staff was positive about access to urgent and routine appointments, and people we spoke to noted improvements in access to appointments.

At our previous inspection in March 2024, we were not assured that all staff attended meetings or had access to meeting minutes where significant events, patient safety alerts, complaints and safeguarding concerns were discussed. There was a link on the practice’s website directing patients to a complaint form; however, this did not work at the time of the assessment in March 2024.

At this inspection we found improvements had been made. Staff told us they attended meetings where learning events were discussed, and we saw evidence of these discussions in meeting minutes. Patients were able to make complaints using the link on the practice website, or by contacting the practice manager via telephone or in person.

We found that patients’ medicines were managed in line with national guidance. Where patients had not attended for reviews, there was evidence of attempts to contact patients asking them to attend. Where necessary, the provider took steps such as reducing the amount of medicine prescribed in an attempt to encourage patients to attend for reviews.

The provider had policies to support medicines prescribing and review of medicines. Medication reviews took place regularly and were sufficiently detailed.

We found missing entries for the recording of refrigerator temperatures on one date. We were told nursing staff would usually check these.The provider told us all admin staff were trained to carry out fridge temperature checks in the absence of practice nurses. However, we found the practice’s processes for ensuring fridge temperatures were always monitored were not always effective.