South Norwood Hill 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, we rated this key question as requires improvement. At this assessment, the rating has changed to Good.

This service scored 78 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

At the previous inspection we found that the practice had not handled a significant event in line with their policy. During this assessment we found that the handling of significant events was appropriate.

The service had a strong proactive and positive culture of safety, based on openness and complete honesty. All staff including non-clinical were made aware of all significant events. They had monthly staff meetings to discuss them, and the agenda and minutes were circulated in case staff were not able to attend.

They actively listened to concerns about safety and thoroughly investigated and reported safety events. Lessons were always learnt to continually identify and embed good practice. Staff gave an example of a significant event which had occurred recently. The incident related to a loss of power which impacted vaccines stored at the practice. The event was documented comprehensively and dealt with efficiently. Lessons learnt had led to improvements in the service. Other significant events had been recorded in the same comprehensive way.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. Staff we spoke with and written feedback we received indicated that staff were very happy with the way the practice responded to and supported them when things went wrong. There were systems in place to ensure learning was shared.

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. The practice held monthly meetings during which, 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. We reviewed the complaints log, and it was managed in line with our expectations. Learning from incidents and complaints resulted in changes that improved care for others.

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 new patients. The practice had a summarising policy for staff to summarise new patients notes. Reception staff had received in-house training, and two receptionists had attended external training.

The service worked with other providers to deliver shared care and when patients moved between services. For example, the practice started to prepare children with learning disabilities for transition from the age of fourteen. This included working with community services. Another example was the follow up of patients discharged from hospital. The practice worked closely with paramedics and a pharmacist for a smooth transition. They maintained oversight of patients moving between services by the care co-ordinators holding weekly meetings with the GPs to discuss.

Information was shared with staff and other agencies, for example through huddle meetings with the community district nursing team and emailing them directly through the IT system.

Referrals and test results were managed in a timely way. Routine results were processed on the same day. If there were urgent results the practice contacted them immediately and aimed to see the patient on the same day. One of the GP’s and the Physicians Associate review results at the end of every surgery session. The practice had additional safety alerts in place for blood results for patients with cancer.

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. It was practice procedure that if a child failed to attend two appointments their parents were contacted and invited in to discuss if there were any problems. If this resulted in any concerns they were escalated swiftly if necessary.

Safeguarding policies were comprehensive and reviewed on a regular basis. There were separate polices that covered children and adults. The policies covered descriptions of the different types of abuse. In addition to this there was extensive detail on signs and indicators for female genital mutilation and child criminal exploitation (county lines). All staff knew and understood the policies content.

The Senior GP was the safeguarding lead and all staff we spoke with and received feedback from, knew this.

All staff we spoke with demonstrated comprehensive knowledge of safeguarding. All GP’s, nurses and care co-ordinators completed training to level 3. All other staff completed training to level 2.

The practice maintained separate lists for vulnerable adults and children. The lists were comprehensive and demonstrated good oversight of the management of safeguarding in the practice. We saw documented evidence of partnership working with other organisations for patients on these lists.

Information about how to escalate concerns to the local authority were available in the reception area, all consulting rooms, and the administration office. Staff described concerns they had dealt with, and this included examples of how they worked in partnership with other organisations.

At the previous inspection not all staff had completed medical emergencies training. During this inspection we saw that all staff had completed medical emergencies training. However, they were completing it mainly on-line, although a limited number of staff had completed recent face to face training. We discussed this with the practice, and they confirmed shortly after the inspection that face-to-face training had been booked for all staff.

Emergency equipment was available and maintained in line with guidance. The practice was set out over three floors and equipment was located on the ground floor. A risk assessment needed to be completed to ensure the equipment could be accessed in a timely manner in the event of an emergency occurring anywhere in the building (e.g. on the top floor). Shortly after the inspection the provider contacted us to let us know they had completed a risk assessment. An action from the risk assessment was the decision to purchase another defibrillator to ensure timely response times to medical emergencies irrespective of where they occurred in the practice.

Staff could recognise a deteriorating patient and knew of action to take. This included staff being trained to identify patients who may have sepsis and how to access urgent help if needed. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

At the previous inspection, the practice had not completed actions recommended in the legionella risk assessment. We reviewed the current legionella risk assessment and saw that the management of water lines was in line with the assessment.

The service had robust systems in place to detect and control potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The practice manager had good oversight of the maintenance contract in place. We saw that gas, fire, and electrical maintenance contracts were well monitored, and checks were carried out in a timely manner. The fire risk assessment was completed annually; the last one having been completed in August 2024. All recommended actions had been completed.

An external company had undertaken health and safety risk assessments and audits. These were completed every 6 months. The most recently completed assessment was in April 2025 and risks identified had been addressed. There was a business continuity plan in place which was monitored and reviewed.

A fire risk assessment was completed annually. The last fire risk assessment was completed in August 2024. We saw that actions from the last assessment had all been completed.

At the previous inspection there were gaps in staff recruitment files, so we were not assured that the practice was following safe recruitment practices. During this assessment we saw that safe recruitment practices were followed. We reviewed 5 staff records which demonstrated the practice collected all relevant documents. The practice carried out enhanced disclosure and barring services checks for all clinical staff and for non-clinical staff who chaperoned. All other non-clinical staff had basic disclosures.

The service made sure there were enough qualified, skilled, and experienced staff, who received effective support, supervision and development. For example, there were two Physicians Associates (PA) at the practice. The senior GP and practice manager had shared responsibility for their development. This included having a clinical reflection form that was completed by the PA at the end of every session. We saw evidence that the PA’s received appropriate supervision. 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 practice. 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. Staff feedback indicated that they were encouraged to develop and had opportunities to complete internal and external training.

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 practice had a designated infection, prevention and control lead and all staff had had relevant training. Cleaning schedules were in place and followed. Every clinical room had an equipment cleaning schedule which were signed and dated by staff. The cleaning schedules for the cleaners had a check list of what needed to be completed at each visit. There was a cupboard for all cleaning materials which was clean, tidy, and well organised.

All rooms had sufficient supplies of liquid soap and paper hand towels. The taps in clinical rooms were lever operated to avoid the risk of re-contamination.

Risk assessments and audits were completed, and actions taken to mitigate risks. We reviewed the last internal infection control audit completed in May 2025. No major actions were identified. Staff told us the nurse completed this audit every 6-8 weeks. We saw copies of the completed audits.

At the previous inspection we found that the review of patient records indicated that medicines safety alerts were not always actioned in a timely manner. During this assessment we found that the provider had effective systems to manage and respond to safety alerts and medicine recalls.

Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring. 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, there was a programme of regular clinical audits of prescribing that focused on improving care and treatment.

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. Blank prescriptions were stored in a safe location and were locked away. Serial numbers on the top and bottom prescriptions were recorded and each time a script was taken staff had to sign for it.

Staff followed protocols to ensure they prescribed all medicines safely, and ensured people received all recommended medicines reviews and monitoring.

Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines, vaccines, and controlled drugs. We saw the logs of the weekly and monthly checks completed by staff.

Waste medicines were recorded and disposed of appropriately including medicines returned by patients. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments.