St Peter's 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 looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment in October 2017, we rated this key question as Good. At this assessment, the rating remains the same.

This service scored 75 (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.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. Representatives from the Patient Participation Group (PPG) felt the provider took concerns seriously and proactively made improvements to the service. Managers encouraged staff to raise concerns when things went wrong. During staff meetings, the whole team discussed and learnt from clinical issues. Staff felt there was an open culture, and that safety was a top priority. The provider had processes for staff to report incidents, near misses and safety events. 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 improved care for others. For example, the service enhanced communication with people by providing clearer information about treatment plans and referral pathways in response to feedback and complaints.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

There were systems in place for processing information relating to people who were newly registered at the service. The service worked with other providers to deliver shared care and when people moved between services. Referrals and test results were managed in a timely way. This was consistent for care home residents, where feedback from care home staff confirmed that the service coordinated care with external services and followed up on referrals to ensure continuity and minimise delays, supporting positive outcomes.

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.

Emergency equipment was available and appropriately maintained. The service was located within a church and had access to an Automated External Defibrillator (AED) which was shared with the church. The AED was located on the ground floor of the church and was accessible from the service. The service was responsible for the calibration of the AED, while the church carried out weekly checks to ensure the equipment was functioning correctly. The service also maintained oversight of these checks through their practice management software. The service maintained multiple large emergency oxygen cylinders. We queried the practicality of transporting a large cylinder to the first floor in an emergency, and the service advised they would explore a more portable option.

Staff could recognise a deteriorating person and knew of action to take. People were advised on risks related to their condition and actions to take if their condition deteriorated.

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

Contracts were in place to ensure the premises were maintained. Health and safety risk assessments and audits had been undertaken and risks identified had been addressed. The last fire risk assessment was completed in 2023, and the service had scheduled a further assessment for June 2026. 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 within the service. We found training was up to date, learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence. Safe recruitment practices were followed.

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 had relevant training. Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks. For example, an audit by the service in May 2026 found that not all GP prescribers had completed an Antimicrobial Stewardship Self-Assessment Checklist, and the service ensured this was completed following the audit.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

Staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely. People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms. Staff received regular training, were competency assessed on medicines optimisation, and felt confident managing the storage, administration and recording of medicines. Staff managed prescription stationery appropriately and securely. Staff followed protocols to ensure they prescribed all medicines safely, and ensured people received all recommended medicines reviews and monitoring. Medicines were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments.

The service had effective systems to manage and respond to safety alerts and medicine recalls. For example, our remote clinical search identified people prescribed a combination of medicines used to treat hypertension, heart failure and chronic kidney disease, and showed that appropriate action was taken to ensure they were informed of the associated risks. Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring. For example, people prescribed a medicine to treat autoimmune diseases had received blood test monitoring within the recommended timescales before prescriptions were issued.

Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. Prescribing data reviewed as part of our assessment confirmed this. For example, the number of antimicrobials issued by the provider was lower than national averages, indicating good prescribing practice. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.