Drs Patel and Partner Also known as Vassall 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 inspection, we rated this key question as good. At this assessment, the rating has changed to requires improvement

The service was in breach of legal regulation in relation to medicines optimisation. This was because not all prescribed medicines were being monitored in line with national guidelines. We also found that non-clinical staff were diverting patients without either clinical input, or thorough guiding protocols.

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.

Staff who we spoke to were aware of how to raise incidents, and they told us that learning was shared with them on both an individual basis, and organisation wide. Leaders detailed how they supported the process, and staff as required.

There was a system for recording and acting on events and incidents. The service provided details of how they had reviewed and investigated all reported events in the past year. The documentation included where learning had been shared with both individuals and the wider team. The service identified themes and took action to improve safety in the service. A weekly newsletter was also in place to share learning from complaints and internal reviews.

The service learned from external safety events and had a system for monitoring patient safety alerts. However, we did note that there were occasions where prescribing was contrary to Medicines and Healthcare products Regulatory Agency (The service did not employ a total triage model notifications). For example, a safety alert from August 2012 stated that simvastatin at doses over 40mg should not be prescribed with amlodipine due to a risk of severe muscle damage. We found 2 patients who were prescribed this, with both having medicines dispensed in 2025.

Staff we spoke to were all aware of care pathways, including referrals and managing care of patients who had been discharged from other services. Leaders at the service shared relevant information with staff in team meetings.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored, and had processes in place to ensure that referrals and discharges were managed quickly. There were also systems in place to ensure that where care was also being provided by community or secondary care providers, information was shared between organisations, such as where blood tests and monitoring were undertaken by another provider.

The practice had a safeguarding GP lead who was allocated time to review patients where there were safeguarding concerns. Staff at the service to whom we spoke were aware of how to make safeguarding referrals and knew the identity of the lead if further advice was needed.

The service worked with other agencies to support patients and protect them from neglect and abuse. Staff took steps to protect patients from abuse, neglect, harassment, discrimination and breaches of their dignity and respect.

The provider carried out staff checks at the time of recruitment and on an ongoing basis where appropriate. Disclosure and Barring Service (DBS) checks were undertaken where required (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable).

All staff received up-to-date safeguarding and safety training appropriate to their role.

The service worked with people to understand and manage risks. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Leaders told us that staff were informed in managing risk, and that standing items such as safeguarding and incidents were discussed at all meetings. Staff reported that they were included in risk management, and that they felt supported and listened to when things went wrong. Staff also received fire safety and health and safety training.

We observed that the building in which the service was in place was fit for use. All equipment had been checked and calibrated as required. The service had a full range of emergency medicines and equipment (such as a defibrillator and oxygen) in place to ensure that emergencies could be safely managed.

Staff at the service were aware of where all emergency equipment was stored. Leaders at the service were able to detail the policies and procedures that were in place to ensure that the environment was safe.

The service had undertaken a full range of risk assessments to ensure that the environment was safe, including premises, and health and safety. Where there was learning from these risk assessments, we saw that the service acted quickly to address any specific issues raised.

There was a range of clinical and non-clinical roles within the practice, and staff received effective support, supervision and development for the most part. We found training was up to date, learning needs and development of staff was managed appropriately.

The service did not utilise a model of care through which a clinician would speak to all patients. Leaders at the service told us that receptionists might redirect patients to other services, including a physiotherapist. There was no formal guidance as to which patients might be referred to a physiotherapist and who might not. Guidance of this kind is needed if receptionists redirect in this way. Although we did not find any incidences where patients had been referred inappropriately, there was insufficient guidance to ensure that a potentially more serious symptom like lower back pain was not inappropriately referred to another service.

Safe recruitment practices were followed. Staff worked together well to provide safe care that met people’s individual needs.

The service had a clear induction program. Staff told us that the induction when they started at the service had been helpful. Staff also received 1 to 1 and team support from managers and received appraisals.

The service made sure there were enough qualified, skilled and experienced staff to provide safe care. Employees who we spoke to said that they felt there were sufficient staff at the practice.

The service assessed and managed the risk of infection. The practice had a designated infection, prevention and control lead and all staff had received relevant training. Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks.

We observed that the service was clean, and all the clinical areas at the practice were fit for use. Curtains were changed regularly, and sharps and other clinical waste management was managed appropriately. Staff we spoke to knew how to access and use a spillage kit when needed.

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

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 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 lower than local and national averages.

The provider had systems to manage and respond to safety alerts and medicine recalls, however they were not always effective.

We also found that the provider did not have effective systems in place to monitor patients who had been prescribed some medicines. We carried out searches on the practice’s clinical records as part of our assessment. For example, we reviewed patients who had been prescribed an aldosterone antagonist for heart failure. We noted that in 10 of the 22 cases, patients did not have the requisite monitoring, of which we fully reviewed 5. Patients are required to have urea and electrolyte monitoring every 6 months, but in 3 of the cases there had been no review in over a year. In 3 cases the last test had shown abnormal renal function. British National Formulary (BNF) guidance is to reduce dose and monitor serum potassium if the estimated glomerular filtration rate (eGFR) under 60mL/min/1.73m2 which it was in 3 of the 5 cases, but this had not happened.

In other clinical searches, we found that all patients who had been prescribed methotrexate had the required blood tests to ensure that the medicine could be prescribed safely. However, we reviewed 5 cases, and in none of the 5 cases was the day on which the once weekly medicine was taken noted. This is required to determine what day blood tests should be carried out. There was also no record that the GP had discussed the risk of infection with the patient in any of the cases.