Gants 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 66 (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. Staff members we spoke with felt supported to raise concerns and felt the management team 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. 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. However, we saw evidence that not all significant events were being recorded as the practice spoke about incidents that had occurred which were not included in the significant events log. There was a system to record and investigate complaints and significant events, 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, 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. We found systems were in place to ensure referrals and test results were 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 maintained systems and processes to respond appropriately when staff suspected someone might be at risk of abuse or neglect, and we saw safeguarding registers were being updated. Safeguarding policies were in place and known to staff and the practice maintained a list of vulnerable people and acted on concerns. However, the practice the practice did not provide evidence of meetings held to discuss safeguarding cases, as there were no recorded minutes of meetings between the practice and healthcare partners between October 2024 and July 2025. The practice had informed us meetings were held to discuss safeguarding concerns, but these minutes were not formally recorded. From our review of training records, we found two members of staff did not have level three safeguarding training. The practice submitted evidence that training had been completed immediately after we had left on the day of the site visit.

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. Shared decision-making was encouraged and facilitated through care plans and communication tools.

Emergency equipment was available and maintained. Patients were advised on risks related to their condition and actions to take if their condition deteriorated. Most staff we spoke with could recognise a deteriorating patient and knew of action to take. Sepsis awareness training had been completed for all staff, however, two members of staff we spoke with could not explain the symptoms of sepsis.

The service detected and controlled potential risks in the care environment across both sites. They made sure equipment, facilities and technology supported the delivery of safe care. However, at the time of the assessment, there were no pull cords available in the toilets for patients with disabilities. The practice had informed us these were being replaced and had them installed immediately after the assessment site visit.

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

The service made sure there were enough qualified, skilled and experienced staff. The practice had a supervision and competency policy which stated that healthcare staff will have access to regular case discussions. However, the provider could not demonstrate documented and formal clinical supervision. There was no evidence of consultation audits or case discussions being completed for clinical staff working at the practice.

We reviewed a sample of clinical and non-clinical recruitment files and saw mandatory documents, such as Disclosure and Barring Service (DBS) checks were stored and secured. However, DBS checks were performed at the start of employment but had not been renewed, with some staff having not had a renewed DBS for over ten years.

There were a range of clinical and non-clinical roles within the practice. We found training for staff, apart from safeguarding training for two members of staff, 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 for both sites 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 made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

Our review of records showed that people taking medicines with specific risks that required monitoring were appropriately monitored before their medicines were prescribed. Regular medicine reviews, including for high-risk drugs, were carried out for people who used the service to ensure their medicines were safe and appropriate to their needs.

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

Staff received regular training, were competency assessed on medicines optimisation, and felt confident managing the storage, administration and recording of medicines. Staff followed protocols to ensure they prescribed all medicines safely, and ensured people received all recommended medicines reviews and monitoring. Medicines were stored securely and at appropriate temperatures.

Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments.

From our review of clinical records, the provider had effective systems to manage and respond to safety alerts and medicine recalls. The practice maintained a drug safety alert list which was accessible to relevant staff.