Atrium Health 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 good. At this assessment, the rating has changed to inadequate.

The service was in breach of legal regulation in relation to safe care and treatment, premises and equipment and staffing.

This service scored 38 (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 did not always have a proactive and positive culture of safety based on openness and honesty. They did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Learning from events was not consistently effective. Following a significant event on 12 May 2026, the service had identified that people waiting unobserved in 1 of the waiting areas could be at risk should a similar incident occur. Whilst the service had discussed potential measures to mitigate this risk and described these to us during our onsite visit, no immediate action had been taken to address the concern. Learning from other incidents and complaints also did not always result in changes that improved care for others.

However, leaders encouraged staff to raise concerns when things went wrong. The service had processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints locally, and when things went wrong, staff apologised and gave people support.

The service did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services.

Test results were not always managed in a timely way. During our onsite visit, on the 19 May 2026, we found 88 test results remained unopened and unactioned, with the oldest dating back to 15 May 2026. The service's policy for managing incoming pathology results stated that there should be no delay in reporting results requiring prompt action and that, during staff absences, the designated clinician should forward results to another appropriate clinician for review.

We had previously engaged with the service regarding the timely management of clinicians' task boxes, including the actioning of test results; however, these concerns had not been fully addressed and remained ongoing at the time of our assessment. During our clinical searches, it was identified the same clinician continued to have urgent flagged tasks recorded as having been started, but there was no evidence within the tasks or people's records to demonstrate the required actions had been completed. We also identified other tasks, including urgent tasks and tasks not yet started, dating back to 14 April 2026. These included actions relating to ongoing monitoring and arranging blood tests, which had not yet been undertaken. This created a risk that people may not receive timely follow-up, monitoring or continuity of care and demonstrated that effective action had not been embedded to prevent recurrence.

However, the service had teams that effectively managed referral pathways with no outstanding or unactioned referrals seen during our onsite visit.

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.

The service held regular meetings with external organisations to discuss vulnerable people and coordinate support where required. Whilst formal minutes were not always recorded, relevant information was documented within people’s individual records and maintained appropriately. Vulnerable people were correctly coded within the service’s clinical system, enabling staff to identify and access records in a timely manner. These arrangements helped staff recognise and respond to safeguarding concerns and share information appropriately to help protect people from avoidable harm.

The service had chaperoning arrangements in place, and staff undertaking chaperone duties had received appropriate training. Both clinical and non-clinical staff could act as chaperones. Where staff did not hold a Disclosure and Barring Service (DBS) check, the service had completed a risk assessment to support them undertaking the role. The service told us it was in the process of obtaining DBS checks for all staff, including both clinical and non-clinical employees.

Following a complaint relating to a non-clinical chaperone, the service had reviewed its processes to ensure people were informed of the chaperone's role and whether they were a clinical or non-clinical member of staff before consultations or examinations took place. Chaperones wore identifiable badges, information about chaperones was displayed throughout the service, and people were offered a chaperone when booking appointments.

The service did not work well with people to understand and manage risks. They did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risks associated with emergency medicines and equipment were not always appropriately assessed and mitigated, and arrangements were not always in place to protect people in the event of a clinical or medical emergency.

The service did not have access to portable suction equipment as part of its emergency equipment. This was not in line with national guidance to support airway management in the event of cardiopulmonary resuscitation. At the time of our onsite visit, the service also did not have a risk assessment to support its decision not to have portable suction equipment available in the service. We raised this with the leadership team based at the service, who provided a copy of a risk assessment after our onsite visit. However, the risk assessment provided did not adequately address the clinical risks of not having access to portable suction equipment and therefore did not demonstrate how these risks had been appropriately mitigated.

During our onsite visit, records relating to checks of other emergency equipment were reviewed. Whilst the service had an automated external defibrillator (AED) available for use in an emergency and there were no concerns identified regarding its functionality at the time of the onsite visit; the service was unable to provide consistent records to demonstrate that routine checks had been completed in line with its own policy and procedures. Such checks are intended to demonstrate the service was assured key pieces of equipment were in full working order in case of medical emergencies.

During our onsite visit, we also reviewed the emergency medicines held by the service. Prednisolone, a corticosteroid medicine used to treat severe allergic reactions and other inflammatory conditions, was listed on the service’s emergency medicines checklist and had been recorded as being present during monthly checks completed by staff in January, February and March 2026. However, the medicine was not present in the emergency bag when reviewed during our onsite visit. When we spoke with staff, they confirmed prednisolone was not stocked by the service despite it being recorded as available during previous checks. This meant the service could not be assured that all emergency medicines it had identified as required would be available if needed in an emergency.

In addition, the service had not ensured other recommended emergency medicines were available in line with national guidance, or that the risks associated with not stocking certain emergency medicines had been appropriately assessed and mitigated. For example, the emergency medicines held by the service did not include diclofenac, for pain relief, or an anti-emetic for nausea and vomiting. Staff advised these medicines were not stocked because they had not previously been required; however, no documented risk assessment was available at the time of our visit to demonstrate how the associated clinical risks had been considered and mitigated. Although a risk assessment was submitted following our onsite visit, it did not clearly outline measures to reduce the identified risks or demonstrate a sufficient understanding of the medicines and their intended use. This indicated the service had not done all that was reasonably practicable to assess and mitigate risks to people in the event of a medical emergency.

Recent clinical team meeting minutes reviewed as part of this assessment showed that a staff member responsible for checking emergency equipment had confirmed they had not been completing these checks. Other staff reported they had been undertaking the checks instead, and leaders were recorded as confirming they were content with this arrangement provided the required monitoring records were completed. However, the lack of clearly defined arrangements reduced assurance that emergency medicines and equipment were being checked consistently. This was reflected in concerns identified during our onsite visit, including how emergency medicines had been recorded as available that were not then present when reviewed.

The service did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

The service had not ensured that the premises were properly maintained by adequately managing identified fire safety risks. Fire risk assessments completed in 2023 and 2025 had both identified a number of medium-risk actions; however, these risks had not been addressed in a timely manner. For example, both assessments identified that combustible materials were being stored under the stairs. During our onsite visit, we observed a similar accumulation of combustible items, including toilet rolls, cleaning stock and broken desk chairs, stored in this area. Both fire risk assessments also identified the need to remove combustible materials from the server room and improve housekeeping standards. During our onsite visit, the server room contained combustible materials, such as broken ceiling tiles, old shelving, plastic cones, plastic storage boxes, unused wires, plastic bottles, paper, used blue roll, and cardboard boxes. We also observed an accumulation of dust across multiple surfaces in the server room, presenting a potential fire risk in that specific room.

Due to the concerns identified during our onsite visit, the Care Quality Commission (CQC) made a referral to the local fire and rescue service on 22 May 2026. The fire and rescue service visited the premises on 29 May 2026 and confirmed that the identified fire risk issues had been rectified. However, the action taken had been in response to our assessment and demonstrated that fire safety risks previously identified by the service had not been addressed in a timely manner prior to our onsite visit, placing people who use the service, staff and visitors at risk of harm.

We observed areas of worn carpet in the reception area that posed a trip hazard to staff. The service had identified this issue on 28 April 2026 within its ‘Fault Log and Maintenance Actions’ records and had assessed it on the same date as a ‘high-risk, high priority’ concern. Whilst the service was able to demonstrate that the issue had initially been reported to the landlord, who subsequently advised it was not their responsibility to rectify, there was no evidence that any further action had been taken to mitigate the trip hazard or reduce the risk of injury to staff. There was also no evidence that plans had been made to repair the flooring at the time of our onsite visit.

Whilst the service had identified several premises-related risks, including damaged flooring and broken seating, it could not consistently demonstrate that these risks had been addressed in a timely manner. Records did not show that interim control measures had been put in place whilst risks remained outstanding. For example, the service had identified broken seating in July 2025 and had assessed this as a high-risk concern; however, no action had been taken at the time of our onsite visit. This meant people who use the service, staff and visitors were exposed to avoidable risks within the care environment.

Environmental audits had identified concerns relating to damaged walls and worn carpets. The service told us these concerns had been raised with the landlord; however, it had subsequently been advised that responsibility for addressing the issues rested with the provider. At the time of our onsite visit, the service had not taken further action to rectify these concerns. This meant known environmental risks within the premises had not been fully addressed.

However, the service was able to demonstrate that some aspects of premises maintenance were appropriately managed. The building had a passenger lift to support access throughout the premises, and records reviewed confirmed that routine servicing and maintenance checks were up to date.

The service did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

During our onsite visit, we reviewed 5 staff records. Of those 5, 2 records did not contain evidence of a Disclosure and Barring Service (DBS) check having been completed at the point of recruitment or before employment commenced, despite both staff members, who were clinical, having worked at the service for more than 5 years. At the time of our onsite visit, the service was unable to provide evidence that appropriate DBS checks had been completed for these staff members. During the onsite visit, leaders told us that a DBS check had been completed for 1 staff member on 6 May 2026 and that a DBS check application for the second staff member had been submitted on 13 May 2026; however, no evidence was available to support this. Following our onsite visit, the service provided evidence that 1 staff member had completed a DBS declaration.

In addition, 1 staff record did not contain evidence to demonstrate that professional registration checks had been completed and verified as valid. At the time of our onsite visit, the service was unable to provide evidence that the required checks had been undertaken. Following our onsite visit, the service provided evidence that the professional registration check had been completed on 24 April 2026 and the member of staff was registered correctly with a professional body.

The service did not consistently provide clinical supervision to staff in line with its own policy. The service's clinical supervision policy stated that all clinical staff employed by, and/or working at, the organisation should receive clinical supervision and that discussions should be documented. However, when we spoke with clinical staff, they told us they had not received clinical supervision. When we requested evidence of clinical supervision sessions, the service was unable to provide records to demonstrate that all clinical staff had received this support. Leaders then advised that clinical audits were used in place of supervision; however, this was not reflected in the service's clinical supervision policy. As a result, the service could not demonstrate that all clinical staff were receiving appropriate support in accordance with its policy.

We requested copies of the audits run in place of clinical supervision. On review, it was noted identified concerns during these audits were not always followed up within the timescales set out in the service’s audit policy. For example, 1 audit of a clinician in December 2025 identified 'red' concerns that required immediate action and a follow-up review within 1 week; however, records shared with us showed this was not completed until approximately 3 months later. At that second review, in March 2026, further 'amber' concerns were then identified, requiring an additional review within 1 month, which had not been completed by the time of our onsite visit. Evidence was also not available to demonstrate what support, engagement or oversight had been provided to the clinician during this period. We raised this with the provider who was unable to account for the lack of action in response to the audits completed.

Whilst staff had completed training deemed mandatory by the service, some staff had been assigned lead roles; however, no evidence was available to demonstrate they had received additional role-specific training to support them in carrying out these responsibilities. Staff told us they held lead roles in areas such as health and safety and infection prevention and control (IPC) and confirmed they had not received any additional training to support them in leading these areas. Staff told us they had completed the same level of mandatory training as all other staff. This meant the service could not be assured staff leading key areas had the knowledge and skills required to effectively fulfil these responsibilities. This created a risk that issues may not be identified, escalated or addressed in a timely way.

However, all dispensary staff were appropriately trained and received annual appraisals to support them in carrying out their roles safely and effectively.

The service did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Clinical waste was not stored securely whilst awaiting collection. Although the waste bins at the service's main site were locked, they were located in an area accessible to the public and were not tethered to a fixed structure in accordance with national guidance to prevent unauthorised removal. As a result, there was a risk that clinical waste could be accessed, tampered with or removed by unauthorised individuals, increasing the potential for exposure to hazardous or infectious materials for people who use the service, staff, visitors and members of the public.

Adequate hand hygiene materials were not always available throughout the premises. For example, during our onsite visit, all but 1 of the hand sanitiser dispensers, including those located along accessible corridors, were empty. This meant people who used the service, staff and visitors were not always able to access hand sanitiser throughout the service when needed to help reduce the risk of cross-contamination and control the spread of potential infections.

During our onsite visit, we observed carpets and fabric furnishings, including chairs in waiting areas, which were visibly stained. The service was unable to demonstrate that these items had been subject to appropriate deep cleaning to reduce the risk of potential infections. External cleaning staff told us that carpet deep cleaning had ceased approximately 12 months before our onsite visit due to damage caused during previous cleaning. However, the service had not identified alternative arrangements or mitigating measures to manage the associated infection prevention and control risks. In addition, the service had not completed an assessment of the risks associated with carpets and fabric furnishings within a clinical environment or identified how these risks would be managed. During our onsite visit, we also observed damaged staff chairs with exposed foam on the armrests, which could not be effectively cleaned. This reduced assurance that the environment and furnishings could be maintained in a manner that supported effective infection prevention and control. Following our onsite visit, the service completed and provided a risk assessment addressing these concerns.

The service had cleaning schedules; however, it was unable to provide evidence that daily and weekly cleaning tasks were consistently completed by the contracted cleaning provider. During our onsite visit, communal areas were noted to be visibly unclean, with dust accumulation and unclean surfaces observed, including on high-touch areas such as the service's check-in screens near the reception desk.

Despite not having appropriate documentation to ensure cleaning schedules were being followed, the cleaning contractor completed monthly environmental cleaning audits, which we reviewed during our onsite visit. These audits identified several concerns, including dusty skirting boards and stained soft furnishings such as chairs and couches. However, the service could not demonstrate that appropriate action had been taken to address the concerns relating to stained soft furnishings or that alternative measures had been put in place to manage the associated infection prevention and control risks. As a result, the service could not demonstrate that all areas of the environment were maintained in a manner that supported effective infection prevention and control.

The service could not demonstrate that it had an up-to-date view of the immunisation status of its clinical staff in line with relevant guidance. Of the 2 clinical staff records reviewed, neither contained complete immunisation information. As a result, the service could not demonstrate staff were appropriately protected against vaccine-preventable diseases or that any associated risks to people who use the service had been assessed and managed. Information relating to staff immunisation status was requested following our assessment but was not provided until after the requested deadline.

The service had a designated infection prevention and control (IPC) lead; however, they had not received any additional training to support them in carrying out this role. Not all staff were aware of who the IPC lead was, as staff identified different colleagues when asked. However, IPC audits were undertaken, which identified actions required to address and mitigate IPC-related risks. The service provided evidence that the identified actions had been completed.

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

As part of our assessment, we conducted a series of remote clinical searches and record reviews.

Out of 915 people prescribed ACE inhibitors, which help manage blood pressure and protect kidney and heart function, 51 people were identified as not having received the required monitoring. We reviewed records for 5 of these people, and 2 had not received the monitoring required in line with National Institute for Health and Care Excellence (NICE) guidelines. Whilst there was evidence that for 1 person, the service had made attempts to engage for the required monitoring, 1 person had only recently been identified by the service as requiring the monitoring.

For people prescribed gabapentin or pregabalin, medicines used to treat conditions such as nerve pain that can be associated with dependence, we reviewed those who had not received a medication review within the previous 12 months. We identified 46 people and reviewed 5 records. Of these, 3 records showed no evidence of a medication review during this period. Gabapentin and pregabalin can be associated with dependence and require regular review to ensure the dosage remains appropriate and the treatment continues to meet the person's needs.

We also reviewed the service’s compliance with Medicines and Healthcare products Regulatory Agency (MHRA) alerts. We undertook a search specifically in relation to Topiramate. This medicine is used for migraine and as an anti-seizure medication and must not be prescribed to women of childbearing age unless they meet the requirements of a Pregnancy Prevention Programme. 6 people were identified by this search and we reviewed 5 records, and 3 records contained no evidence a pregnancy prevention plan was in place and all 5 had no annual risk acknowledgement forms completed.

A sample of records was reviewed to identify whether people had received appropriate medication reviews within the previous 3 months. We found that medication reviews had not been completed consistently. Some people had received a medication review within the expected timeframe, whilst others had not received a review within the previous 3 months. This meant the service could not demonstrate that people's medicines were being reviewed consistently in line with its processes.

The service could not demonstrate that prescribing practice was consistently reviewed for all non-medical prescribers. We were told prescribing audits were undertaken by a centralised team and reviewed by the service's clinical lead. However, evidence was not available to demonstrate that prescribing audits had been completed for all non-medical prescribers, including a member of staff who had been prescribing since 2025. This reduced assurance that prescribing practice was being routinely reviewed to identify risks and support safe prescribing.

The service responded immediately to our clinical searches findings by contacting the people identified through the searches who required monitoring and medication reviews. Records provided following the searches showed that people were contacted and follow-up appointments or reviews were arranged where required, including for those who had not responded to previous requests. Although the service took prompt action once these concerns were identified, the gaps found meant some people had not received the monitoring or medication reviews they required within the expected timeframe.

However, all Patient Group Directions (PGDs) and Patient Specific Directions (PSDs) were up to date, regularly reviewed and kept current in line with national guidance. (PGDs are written instructions that allow healthcare professionals to supply or administer certain medicines to groups of people without a prescription. PSDs are written instructions for an individual person, tailored to their specific health needs).

Arrangements for the ordering, storage and disposal of medicines were appropriate at both the main site and the branch dispensary. Medicines requiring refrigeration were stored and monitored appropriately. Staff checked and recorded refrigerator temperatures daily to ensure medicines were kept within the required temperature range. Controlled drugs and medical gases, such as oxygen, were stored safely and subject to the required safety risk assessments.

There were safe systems in place for the management and dispensing of medicines within the branch dispensary. The dispensary was overseen by a lead GP, and detailed standard operating procedures (SOPs) covered all aspects of dispensary activity and were reviewed regularly to ensure they remained up to date. Prescription stationery was stored securely, and effective systems and records were maintained to monitor and track its use across both the main and branch sites. The dispensary could arrange medicine deliveries for some people, with appropriate procedures in place and risks associated with this process having been assessed. Systems were in place for reporting incidents and dispensing errors, and medicines safety alerts and recalls were received, reviewed and acted upon where relevant.