Cape Hill 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 Good. At this assessment, the rating remains the same.

This service scored 69 (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.

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. The provider had processes for staff to report incidents, near misses and safety events. The practice had a significant events policy, and a reporting form was in place, which was accessible to all staff members. Staff felt there was an open culture, and that safety was a top priority. Evidence provided by the practice showed they had recorded 14 significant events in the past 12 months. These were discussed with staff to share learning and to mitigate any future risks.

There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Information reviewed demonstrated that people had opportunities to provide feedback, and they knew how to make a complaint. Lessons were learnt from individual complaints and shared with the practice team to improve the quality of care. Feedback and information were available in the practice and on their website.

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.

Effective systems were in place for processing information relating to new people including the summarising of new records. The service worked with other providers to deliver shared care and when patients moved between services. We found clinicians made appropriate and timely referrals in line with protocols and up to date evidence-based guidance. This was supported by a system in place to ensure all patient information including laboratory test results and referrals were reviewed and actioned in a timely manner.

The provider told us that there were processes in place that were monitored and managed to keep people safe. For example, the provider was part of the Primary Care Network (PCN) and attended regular meetings with other agencies across the locality to share and discuss information relating to patient care and treatment.

There were a range of structured meetings in place. These included safeguarding, multi-disciplinary meetings and reception team meetings. Clinical meetings were held every week, where staff had the opportunity to discuss any concerns, and the leadership team had the opportunity to discuss and share learning.

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.

There was a safeguarding lead for children and adults, and all staff were aware of who to speak to if they identified a safeguarding concern. Safeguarding registers were regularly reviewed but on reviewing a random sample of patients on these registers we found adults within the same household were not linked with children where there was a safeguarding concern identified.

There were processes in place to follow up children and young people who were not brought to their appointments with the provider and for secondary care appointments.Safeguarding meetings were held every 3 months. Community teams were invited and information was shared appropriately for the care of people with safeguarding and vulnerable concerns.

There was a policy in place for the renewal of DBS checks for clinical staff. Non clinical staff completed a self-declaration form, however there was no process in place for newly employed administrative staff to have a DBS completed or a risk assessment had been completed. We discussed this with the leadership team, who planned to review the recruitment processes they currently had in place to ensure the appropriate checks or risk assessments were in place for future recruitment. Records we examined showed that clinical staff had a DBS check in place. 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.

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.
All staff were trained in basic life support and staff could recognise a deteriorating patient. Staff were aware of what actions they would take if they had a deteriorating patient and had completed sepsis awareness training. Patients were advised on risks related to their condition and actions to take if their condition deteriorated. Emergency equipment was available and maintained.
Leaders told us that they worked with services locally to understand and manage risks. The practice also had registers in place to support those patients who were vulnerable or who had mobility or communication needs.
 

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Health and safety related assessments and procedures to manage health and safety were in place. A health and safety risk assessment and fire risk assessment had been completed. The latest fire risk assessment had been completed in November 2025.

We found staff had been provided with training in health and safety related topics such as fire safety, infection control, basic life support and resuscitation training, however some staff required updates. Staff reported during discussions that they had no concerns regarding the arrangements in place to ensure health and safety. The fire risk assessment highlighted that all staff had completed fire training, however on reviewing staff training files at the onsite assessment we identified gaps in fire and health and safety training. Following the onsite assessment, we received evidence to demonstrate that all staff had completed training updates.

There were policies and procedures in place for the management of health and safety. Fire safety policies were in place and staff were aware of how to access these. Fire marshals had undertaken additional training for the role. Systems were in place for the regular checks of fire alarms, extinguishers and fire evacuation procedures. Regular monitoring was in place to ensure guidelines were adhered to and all staff had been made aware of the appropriate procedures to follow.

The practice had completed assessments in place for the control of hazardous substances. Evidence provided by the practice showed equipment was regularly calibrated and electrical items were PAT (portable appliance testing) tested.

There was a business continuity plan in place which was monitored and reviewed.

During our site visit we found the premises were well maintained. The provider detected and controlled potential risks in the environment. They made sure equipment, facilities and technology supported the delivery of safe care. Regular checks were carried out on the premises, facilities and the equipment provided. Contracts were in place to ensure the premises were clean and well maintained. Clear signage around the building supported people and staff in the event of an emergency evacuation.

The service had qualified, skilled and experienced staff who received effective support, supervision and development, however training updates were not routinely monitored to ensure all staff were up to date with training deemed mandatory by the practice. They worked together well to provide safe care that met people’s individual needs.

The clinical leadership team had systems in place for the monitoring of staff, which included regular conversations as part of their clinical supervision and random audits of clinical staff’s consultations.

We identified gaps in training, for example, health and safety and fire safety. Following the onsite assessment, we received evidence to demonstrate that staff had completed their training updates. Staff development was managed appropriately and staff were working within their agreed areas of competence.

The practice had recruitment policies in place; however, we found that disclosure and barring service (DBS) checks were only completed for clinical staff. Non-clinical staff completed a self-declaration form. There was no process in place for newly employed staff in administrative roles to have a DBS check completed to ensure they were safe working in an environment where they may have contact with children or adults who may be vulnerable.

We reviewed 4 personnel files and found appropriate checks such as previous employment record and proof of identity checks had been completed. Immunisation status for clinical staff was not complete. There was no evidence to demonstrate that staff in non-clinical roles had been immunised for Hepatitis B or given the opportunity to receive the vaccination and no risk assessments had been completed to ensure staff and patients were not at risk. Personnel folders were well organised and there was a systematic approach to ensure that personnel folders were managed appropriately.

There were a range of clinical and non-clinical roles within the practice and the practice was a training site for GP registrars and medical students. GP registrars are doctors who have completed medical school and the first years of their postgraduate training and are in the final stages of specialist GP 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.

An infection control audit had been completed to identify potential risks and take appropriate action where required. At the time of the onsite assessment, the audit provided to us had been completed in August 2025, and the practice had achieved 97% overall.

The practice had a designated infection, prevention and control lead and all staff had completed training relevant to their role. Staff were aware of the systems and processes to follow to ensure clinical specimens were handled safely.

The practice had policies in place for infection, prevention and control which was accessible to staff and staff were aware of the action to take. For example, in the event of a sharps or contamination injury.

The service did not always ensure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

As part of the assessment, we carried out remote clinical searches to review how patients’ medicines were monitored and if the appropriate care and treatment was being received. We reviewed patients who had been prescribed Aldosterone Antagonist medicines. Aldosterone Antagonist medicines are used in the treatment of high blood pressure and heart failure. The clinical search identified potentially 12 out of 34 patients on these types of medicines who had not had urea and electrolyte (UE) monitoring within the past 6 months. We reviewed the records of 5 patients and found 2 patients were overdue monitoring.

A second search was completed to review the number of patients prescribed bisphosphonate for 5 years or over. Bisphosphonates are medicines that are used to treat and prevent osteoporosis. The search identified 28 patients. We reviewed a random sample of 5 clinical records and found all the patients had received the appropriate monitoring.

We carried out a search to identify patients who had received a medication review in the past 3 months. The search identified 1165 patients. We reviewed a random sample of 5 records and found thorough medicine reviews had been completed by the GPs and clinical pharmacists.

The practice worked with a third party provider, who provided clinical pharmacy support to monitor people and the prescribing of medicines. The provider was aware of safety alerts issued by the Medicines and Healthcare products Regulatory Agency (MHRA); however, we were unable to gain assurances from the clinical team of the system in place to ensure alerts were acted on. We carried out a clinical search on ACE/ARB medicines plus aldosterone antagonist medicines used for the treatment of patients with heart failure which had potential risks to cause high potassium levels, to check if patients had a urea and electrolyte (UE) test within the past 6 months. We reviewed a random sample of 5 clinical records and 4 out of the 5 patients were overdue monitoring.

There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.

Emergency medicines, vaccines and medical equipment had clear monitoring processes in place. We found the defibrillator was not in a place where it was easily accessible. There were appropriate arrangements in place for the management of vaccines and for maintaining the cold chain and a data logger was in place. We saw fridge temperatures were routinely monitored and vaccines reviewed at random were in date and stored appropriately. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments.

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 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 local and national averages.