Westminster 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. The rating remains good following this assessment.

This service scored 63 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Processes were in place for staff to report incidents and near misses. Leaders told us how they encouraged staff to raise concerns when things went wrong. Staff told us that they knew how to report a safety event and that they would be supported to do so.There was a process to review significant events over a 12-month period to identify patterns and trends.

We noted that a low number of significant events (12) had been reported in the last 22 months which may indicate that the provider needs to review their reporting systems to ensure they are effectively capturing all incidents. We reviewed a sample of significant events and found that a record had not been made to show they had been revisited to ensure the actions taken had been effective. We saw a significant event that indicated out of date medicines were found in the fridge, at this assessment we also found out of date medicines in the fridge. The provider told us how they had addressed this following the assessment.

Clinical staff said learning from significant events and complaint investigations was shared with them. A number of non-clinical staff did not think that this information was shared with them or that there was a clear process for doing so unless they were directly involved in the event or complaint. We brought this to the attention of the provider so that they can review their processes for information sharing.

The provider worked with people who used the service and healthcare partners to establish and maintain safe systems of care. There were processes to share information with staff and other agencies to enable them to deliver safe care and treatment. Clinicians followed care and treatment pathways for treating and referring patients to other services. Referrals to secondary or specialist care were made promptly, and urgent referrals for suspected cancer were followed up appropriately. There was a system to oversee and act on patient test results.

Members of the staff team were aware of local services and support networks that they could refer patients to in order to support them with their needs and to prevent ill health. Some reception staff had been trained in care navigation to direct patients to the most appropriate service or services to meet their presenting needs. The provider was awaiting availability on a training course to enable the remainder of the team to be trained.

The service safeguarded people from the risk of abuse. There were systems and processes to respond when it was suspected that people may be subject to abuse or neglect. Staff had been provided with safeguarding training, and they had a clear understanding of safeguarding and how to take appropriate action to respond to concerns. Alerts were added to the patient record system when there were safeguarding concerns about a patient so that all relevant members of the staff team could easily identify this. There was a process to monitor patients when there was a safeguarding concern identified. The service worked with partner agencies to share information to safeguard people.

The service worked with people to understand and manage risks. A system was in place to respond to medical emergencies. Staff had received training in basic life support, and a training update was imminent. The reception team had not received specific training on spotting the signs of sepsis. All staff had access to guidance on identifying sepsis.

Patients were advised on risks related to their condition and actions to take if their condition deteriorated. Patients were directed to the most appropriate clinician or service to meet their needs and this included supporting people that may need urgent care and treatment. Staff were trained in areas to support people who lived with long-term health conditions, for example, diabetes. Patients were called in for regular checks on their health when they were living with a long-term condition. People who used the service were referred to services that could provide them with specialist advice to manage their condition and the risk of deterioration.

The provider had systems in place to identify and manage potential risks in the environment. They made sure equipment and facilities supported the delivery of safe care. Regular checks were carried out on the premises, facilities and equipment provided. Contracts were in place to ensure the premises were well maintained. Health and safety related assessments and procedures to manage health and safety were in place. Staff had been provided with training in health and safety related topics such as fire safety and infection prevention and control (IPC). There was a business continuity plan in place to provide guidance for dealing with a major disruption to the service, for example an IT failure. Overall, staff reported satisfaction with the work environment. Some staff reported that improvements were needed to equipment.Following the assessment the provider told us about the improvements they had made and further improvements planned.

Staff received support and opportunities to develop. All new staff underwent an induction programme and were required to undertake mandatory training within an appropriate timescale. We noted that although new clinical staff had a role specific induction, this was not recorded. This was recommended at the last inspection. There was a system to monitor staff training to ensure mandatory updates were completed. Staff told us they were supported to develop their skills and learning. Records showed that staff had received an appraisal within the last 12 months. Staffing levels were reviewed and the majority of staff told us that they felt there were enough staff to provide safe care, and they worked effectively as a team.

The provider made sure that staff were suitable for employment. We looked at the recruitment records for a sample of staff. These showed recruitment practices were carried out in line with legal requirements. The immunisation status of staff had been recorded where possible with a risk assessment in place where this could not be accessed.
 

The facilities and premises were appropriate to support cleaning and infection prevention and control (IPC) management overall. Some furnishings in the staff kitchen had worn coverings which would not promote good infection prevention and control. Procedures were in place to prevent the risk of infection. Staff had been provided with training in IPC. Personal protective equipment was in sufficient supply and located appropriately around the premises. Cleaning equipment was stored securely. Cleaning schedules were in place and IPC cleaning audits were carried out. The last IPC audit was carried out by an external health service in November 2025 with a score of 98% compliance. Actions arising from this audit related to improving the décor and furnishings to enable easy cleaning. The provider told us that that this was planned.

We reviewed clinical records for patients who had been prescribed medicines which required routine monitoring. Our review showed that medicines were managed safely and in accordance with relevant best practice overall. However, we identified that improvements were needed to the processes for ensuring people had an annual medication review. We found 20% of people prescribed 10 or more medications and 35% of patients prescribed gabapentinoids (a medication for pain management) had not had a medication review in the last 12 months. Medication reviews were not standardised, and some did not contain sufficient detail. Following the assessment the provider told us how this had been addressed.

The provider had effective systems to manage and respond to safety alerts and medicine recalls.

The provider was aware of and acting upon prescribing data to improve the prescribing of medicines generally and where data showed prescribing of higher risk medicines were higher than local and national averages. Our review of data showed improving trends in this. The provider told us how they were working to reduce this prescribing through auditing and quality improvement projects.

Blank prescriptions were securely managed. However, improvements were needed to the records to enable accurate auditing.

Vaccines were appropriately authorised. We found some out of date medicines and found that a few daily checks of fridge temperatures had not been recorded. We found a vaccine fridge plug was not labelled to avoid it being accidentally unplugged. This was addressed following the assessment.

Checks of emergency equipment and medicines were carried out. However, emergency equipment was checked monthly instead of weekly. The medical oxygen was not secured to prevent it falling over and was close to a radiator. This had not been identified by the risk assessment for the oxygen cylinders. This was addressed following the assessment. A risk assessment for the emergency medications held was made available following the assessment.

The provider told us how they reviewed the prescribing practices of non-medical prescribers. A formal process to demonstrate their competence had been put in place.