St Johns Wood Medical Practice

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 August 2017, we rated this key question as good. At this assessment, the rating has changed from good to requires improvement. The service was in breach of legal regulation in relation to safe care and treatment. We found issues related to safeguarding, safe environments, clinical care, emergency medicines and emergency equipment. We found that some required items were not available for use in the event of a medical emergency and staff training was not up to date.

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.

The service had a 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. Staff were encouraged to raise concerns when things went wrong. Lessons learnt from complaints and significant events were discussed during staff meetings and recorded in the minutes to ensure improved care for all patients.

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 service worked with other providers to deliver shared care and when patients moved between services. Referrals and test results were managed in a timely way.

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. Staff were aware of safeguarding procedures, but not all staff were appropriately trained. For example, the adult safeguarding lead at the practice had not completed safeguarding training since 2023 and the level completed was level 2. The service maintained a safeguarding register and acted on concerns working in partnership with other organisations. However, records of patients on the safeguarding register we reviewed, showed that not all household members of such patients were coded.

The service did not always 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. Emergency equipment was not complete and appropriately maintained. The practice told us that the hospital was responsible for responding to any medical emergency on the premises and the target response time was within 3 minutes. The policy related to responding to a medical emergency was unknown to the new clinical staff until we made them aware of it when speaking with them. There was no evidence of regular checks to ensure that emergency medicines and equipment met the required standards. For example, there were no paediatric defibrillator pads for use in an emergency. Two oxygen cylinders were out of date and not removed from the other 3 cylinders that were in date, to avoid any confusion in an emergency; oxygen tubing was stored away from the equipment with which it would be used; not all sizes of oropharyngeal airways (a medical device used in unconscious patients to prevent the tongue from blocking the airway) and portable suction were available. Many of the items used in the resuscitation of a patient in cardiac arrest were missing or out of date. However, staff could recognise a deteriorating patient and demonstrated an understanding of the actions required in response. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. The premises were not owned by the practice. The cleaning contracts in place to ensure the premises were maintained were held by the building owner. The fire risk assessment was current and fire drills, and alarm testing were recorded. However, the practice did not have a system to ensure any action recommended from the risk assessments were completed timely by the landlord to be assured of patient and staff safety. We found a room used by one of the staff of the practice that did not have windows for ventilation creating a health risk for the staff and patients during appointments. There was a business continuity plan in place which was monitored and reviewed. Calibration of clinical equipment was routinely completed and the certificates seen during the assessment process.

The service made sure there were enough qualified, skilled and experienced staff. They worked together well to provide safe care that met people’s individual needs. Safe recruitment practices were followed and staff worked within their agreed areas of competence. They made sure staff received effective support, supervision and development. However, our review of staff training records showed that not all staff had completed their required training. For example, fire safety training, infection control training, safeguarding adults training and chaperone 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 (IPC) lead, risk assessments and audits completed with actions taken to mitigate the risks. However, not all staff had completed the relevant training. We reviewed 5 staff records and 2 had not completed IPC training while another had completed level 1 IPC training in October 2024. This was an issue identified at the last assessment in August 2017 for staff to be aware of IPC policy.

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. Patient group directions (PGDs) were current and authorised by appropriate clinicians. Patient specific directions (PSDs) used by the health care assistants at the practice were documented in the patient records. However, the process of scanning and filing was not always followed as our review during the site visit identified that not all authorised PSDs were scanned and filed.

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. However, during the site visit, we found that storage of vaccines needed to be reviewed as this task was completed by the administrative staff because there was no permanent practice nurse working at the location and there was no evidence that the staff who took on this responsibility had completed the suitable training to do so. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines. A data logger was used to back up manual readings of vaccine fridges and staff understood the protocol to follow if temperatures were out of recommended range. However, the practice checked the data logger monthly when it should be recorded at least once a day during the working week according to the Green Book guidance (guidance on storage, distribution and disposal of vaccines by the UK Health Security Agency (UKHSA)). The practice took the feedback on board to improve medicines safety. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments. However, there were no risk assessments completed for emergency medicines that were not kept by the service such as naloxone and opiates. The practice did not have antiemetics (medicine to stop nausea and vomiting) in the emergency medicines. Emergency medicines for the treatment of severe pain such as morphine, pethidine and diamorphine were not stocked by the practice but they had diclofenac injection (another medication for treating pain).

Staff followed established processes to ensure people prescribed medicines with specific risks received the recommended monitoring. They also followed up with patients who did not engage with the service to ensure required blood tests were completed. However, the context of medication reviews was not always recorded.

Our review of patient records during the clinical searches showed that patients on high-risk drugs (medicines to treat heart failure) were overdue recommended monitoring. We reviewed 5 patient records and we found 4 of them to be overdue and the other patient was abroad and had 2 months’ supply of the medicine. The process of responding to Medicines and Healthcare products Regulatory Agency (MHRA) alerts needed to be reviewed. For example, 4 out of 5 female patients whose records were reviewed were on medicines that could cause birth defects did not have effective pregnancy prevention plan or the annual risk assessment forms completed.

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 in line with the local and national averages. In addition, the number of prescribed psychotropics and hypnotics was in line with the local and national averages. There was no evidence of a programme of regular clinical audits of prescribing that focused on improving care and treatment. The practice did not complete 2-cycle audits to ensure quality improvement of medicines management. Clinical audits submitted by the practice was not qualitative and there was no evidence of learning gained from them.