Belmont Health Centre Also known as Dr J Wijeratne & Parnters

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 the last assessment in July 2018, 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 (regulation 12).

This service scored 59 (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 to about safety and investigated and reported safety events. Managers encouraged staff to raise concerns when things went wrong. However, lessons from complaints and significant events were not always recorded after investigation. Lessons were not always shared with staff during staff meetings or recorded in the minutes to embed it into daily practice.

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 did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. Staff were trained on safeguarding procedures at the right level appropriate to their roles. The practice had a safeguarding policy, it included information about who staff could report concerns to in addition to the safeguarding lead. Not all children on protection plans who had safeguarding alerts were linked to their parents and other household members. Our review of the safeguarding register looked at 5 patient records; 3 records did not have household members linked leaving the patients at increased risk of harm. The practice added the alerts to all the patients identified while CQC was on site.

The service worked with people to understand and manage risks. Emergency equipment was available and maintained. Staff were trained on how to respond to emergencies.

The service did not always detect and control potential risks in the care environment. Risk assessments were completed but they did not always make sure facilities supported the delivery of care. For example, action plan recommendations from the fire safety risk assessment (December 2025) and the Legionella risk assessment (January 2024) had not been completed. There was no evidence of completion of the recommended action plans. This was only provided after the site but the dates of completion of the action plans were not included. For example, there were no dates of completion of the fire risk action plan which the service obtained from the building owner. Fire drills were completed weekly and recorded. There was a fire action notice visible at the reception and there were named fire marshals at this service. There was a fire evacuation procedure for staff and visitors to follow. The cleaning of the premises was contracted to a third-party company. The premises were clean during the site visit. There was a business continuity plan in place which was monitored. The branch surgery at 252 Long Elmes in the London Borough of Harrow was not in service due to structural issues (visible cracks on the walls, loose roof tiles). The service informed us that the landlord and the ICB were aware of the issues with relevant correspondence shared with CQC. We informed the service to update CQC when the branch surgery becomes operational to conduct a reassessment.

There were a range of clinical and non-clinical roles within the practice. 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. Staff were qualified, skilled and experienced. They received support and supervision. However, staff we spoke to during the site visit told us that the staffing level was not always sufficient to deliver the care needs for the patient population.

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 relevant training. Audits were completed but evidence of completion of action plans recommended from Legionella risk assessment was not provided except for a handwritten documentation about completion by the building owner. Following the site visit, the service shared with CQC further documentation obtained from the building owner.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always follow protocols to ensure they prescribed all medicines safely and ensured people received all recommended medicines reviews and monitoring. When we reviewed the patient records, we found 63 patients who had a potential of missed diagnosis of diabetes whose blood sugar level was higher than acceptable level with blood test results received in 2023. These patients were not placed on the diabetes register to ensure proper diabetes care and monitoring was received.

Another example was that of 2 patients on Citalopram (medication to treat low mood and panic attacks) aged 65 years and over who did not have their dosages reduced in accordance with the historic MHRA safety alert. In addition, 2 patients on blood thinning medication did not have the dosage reduced despite instruction from the secondary care provider to do so. A patient living with asthma did not have adequate assessment prior to steroid prescription. We found medication reviews completed were not always discussed with the patients and context of the medication reviews recorded. We found 2 patients on medications to protect the heart and kidneys who had received prescriptions without appropriate tests and monitoring. Following the site visit, the service informed us that they had started to take steps to resolve the concerns.

Medicines were stored securely and at appropriate temperatures with adequate coverage made for any disruption to electricity. The prescribing data reviewed as part of our assessment showed that the provider prescribed antimicrobials at a level lower than or not varied from local and national averages. Emergency medicines and equipment were provided and well-maintained. Fridge temperature checks were monitored and records maintained. Blank prescription forms were stored securely and appropriately.