Royal Arsenal 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 Inadequate. At this assessment, the rating has changed to Requires improvement.

The service was in breach of Regulation 12 (Safe care and treatment) in relation to and medicines optimisation. This was because not all prescribed medicines were being monitored in line with national guidelines, medication reviews did not always contain sufficient information, and the practice did not always inform patients of the associated risks of taking certain medicines.

This service scored 62 (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 about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. Whilst most staff felt learning was shared effectively, some staff reported this was not the case.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. 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.

The service worked with people and healthcare partners to establish and maintain safe systems of care.

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. However, referrals and test results were not always 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.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations.

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.

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. All staff had received sepsis awareness training.

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.

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

The service did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Many of the clinical issues identified during this assessment had also been noted in the previous assessment in December 2024.

We reviewed clinical records for patients who had been prescribed medicines which required routine monitoring. We identified 806 patients who were prescribed an angiotensin converting enzyme (ACE) or angiotensin receptor blocker (ARB) medicine, of which 36 patients had not received the required monitoring. ACE and ARB medicines are used to treat patients experiencing high blood pressure or heart failure. We reviewed 5 patient records and found that evidence that all of these patients had been invited by the practice to have their monitoring completed. However, one of these five patients had not had their kidney function reviewed since 2018. Patients taking ACE and ARB medicines are at increased risk of developing hyperkalaemia (increased potassium in the blood) or acute kidney injury.

During our remote clinical records searches, we identified 5 out of 24 patients who were prescribed mirabegron and had not received the required blood pressure monitoring. Mirabegron is a medicine prescribed to treat patients with an overactive bladder. We did not find evidence that the practice was actively monitoring the blood pressure of any of these five patients as per national guidelines.

We identified 2 patients with a potential missed diagnosis of diabetes. We reviewed both of these patient records. One of these patients did not have the appropriate blood test repeated within the timeframe specified in NICE guidelines. This patient had received the repeated blood test approximately 9 months later than specified by the guidance. The practice stated that this patient has since been called in for review.

We identified 25 out of 105 older patients who were prescribed a non-steroidal anti-inflammatory (NSAID) or antiplatelet (blood thinning) medicine without a proton-pump inhibitor (PPI) medicine. A PPI medicine should be used alongside NSAID and antiplatelet medicines to prevent the likelihood of gastric bleeding in this patient group. We reviewed 5 of these patient records and found all patients required a PPI, but that this had not been prescribed, with no evidence of the associated risk being identified or considered.

The practice did not always document sufficient information within patient clinical records. We searched for the records of people who had received a medication review within the past 3 months. We sampled 5 of these patients, and found that 3 out of 5 of these patients had insufficient information contained within their electronic patient record detailing what was undertaken during the review. These 3 patient medication reviews were coded, but with no documented evidence of a medication review having been completed.

Our remote clinical records searches identified 13 patients who were prescribed methotrexate (a medicine prescribed to treat inflammatory conditions by supressing the immune system). This medicine should be taken by a patient once per week. We reviewed 5 of the 13 patients prescribed methotrexate and found that none of the 5 patients had the day of the week specified on their prescription in which they should take their medicine. The practice reported that this would be remedied by their pharmacist as soon as possible.

The practice told us that they would address these omissions and review all identified patients following the assessment.