Thornton Heath 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

At our last assessment, we rated this key question as Good. At this assessment, the rating remains the same.
We looked for evidence that people were protected from abuse and avoidable harm.
The service had a good learning culture and people could raise concerns. Managers investigated incidents thoroughly. People were protected and kept safe. Staff understood and managed risks. The facilities and equipment met the needs of people, were clean and well-maintained and any risks mitigated. There were enough staff with the right skills, qualifications and experience. Managers made sure staff received training and regular appraisals to maintain high-quality care. Staff managed medicines well and involved people in planning any changes.
 

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice 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.
The complaints policy was reviewed in February 2026. The practice had received 4 complaints in the previous 12 months. The significant event policy had been reviewed in August 2025. Staff reported a learning culture where staff were encouraged to report significant events which would foster learning and help prevent the recurrence of similar incidents in the future.
 

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 practice had a dedicated administrator to follow up non-clinical referrals, and the practice used their electronic system to send tasks to GPs if they needed to follow up.

The practice 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.
We saw a joint adult and child safeguarding policy that was reviewed in January 2026.
Staff were aware who the safeguarding lead was. The practice had oversight of a list of vulnerable people that was reviewed regularly. Vulnerable people were coded on their system and had alerts added to their records. Safeguarding meetings were held monthly, and regular communication was maintained in between these meetings. All clinical staff had completed level 3 safeguard training and non-clinical staff had completed level 2.
 

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 maintained. Staff could recognise a deteriorating patient and knew of action to take. Patients 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. There was a business continuity plan in place which was monitored and reviewed.
The practice manager had oversight of contracts and maintenance for the building and equipment; however, the owner of the building was responsible for undertaking all maintenance. We saw the practice had undertaken portable appliance and calibration of electrical equipment testing.
Fire alarm tests were carried out weekly; fire extinguisher checks were carried out annually. The practice had 1 fire warden.
A health and safety risk assessment had been undertaken in April 2025, there were a few actions, all had been addressed.
 

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 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. Safe recruitment practices were followed.
The recruitment policy had been reviewed in January 2026. We reviewed 5 staff records, which were complete, all files contained the necessary recruitment checks. This included, references, proof of identity and Disclosure and Barring Service (DBS). All staff (clinical and non-clinical) were up to date with role specific training. A partner informed us non-medical prescribers had weekly supervision although this was not formally documented.
The practice informed us they had access to the South West London Training Hub, which gave staff access to a range of training courses.
 

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. Risk assessments and audits were completed, and actions taken to mitigate risks.
 

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. For example, 1 clinical search identified that 19 patients were not always involved in managing risks in line with evidence-based guidance. The search showed 4 out of 5 patients sampled with previously raised HbA1c (a measurement of sugar levels in your blood) not on the Diabetes register. Two patients had missed diagnoses of diabetes, and 2 other patients had not had appropriate follow-ups of their raised blood sugar levels. This was a risk to patients as they were not receiving the care they should, which could lead to future complications. Once this concern was raised the practice informed us, they would review these patients and discuss them in a clinical meeting.
Overall, 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 including controlled drugs were stored securely and at appropriate temperatures.
Daily records of the maximum and minimum temperatures of the fridges were recorded. Staff were aware of what to do if any fridge had temperature readings outside of the required range. All fridges were lockable to ensure only authorised staff could access them.
Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines, vaccines, and controlled drugs. 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. 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.