The Southall 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 in November 2016, we rated this key question as Good. At this assessment in July 2026, the rating remains the same. However, we found some minor issues related to patient safety and clinical care which were addressed promptly by the service.

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. 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. Staff were encouraged to raise concerns when things went wrong. Lessons learnt from complaints and significant events were discussed during staff meetings and recorded in the minutes to ensure an improved care for all patients.

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. 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 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 service maintained a safeguarding register and acted on concerns working in partnership with other organisations.

The service did not always work well with people to understand and manage risks. They did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. This was because not all emergency equipment was available and maintained. For example, not all items recommended by the Resuscitation Council UK, needed for early resuscitation were in place. There were no risk assessments sufficiently considering the risks and impacts to support the rationale or decision not to have them. Items not available included a portable suction, oropharyngeal airway devices in different sizes, self-inflating bags with reservoir (adult child), clear face masks in different sizes, a supraglottic airway device, a thermometer, a sphygmomanometer and a pulse oximeter. 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.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The premises were managed by a private landlord and all maintenance checks carried out appropriately. Health and safety risk assessments and audits had been undertaken and risks identified had been addressed. The fire risk assessment was current and recommended action plans completed by the building owner. There was a business continuity plan in place which was monitored and reviewed. The premises were visibly clean during the site visit. There was a cleaning contract with an external company and a cleaning schedule was maintained. However, the cleaning schedule at the branch surgery was not always maintained and a visit to the premises showed that more needed to be done to ensure the cleanliness of the toilet used by patients at the branch. Following the site visit, the practice shared the cleaning schedules obtained from the external company.

The service did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs. This was because during the assessment process and site visit, we noted that there was no regular practice nurse at the service which had an impact on the supervision of other nursing staff such as the health care assistant. Our review of staff training record showed that not all staff had completed the required 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. The practice had a designated infection, prevention and control lead and all staff had had relevant training. Risk assessments and audits were completed, including Legionella risk assessment and actions taken to mitigate risks. Water safety was maintained at the practice.

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. Staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely. 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.

Patient group directions (PGDs) authorised by appropriate clinicians were out of date. We found that more oversight was needed for the patient specific directions (PSDs) used by the health care assistant at this service to ensure the right authorisations were always used. For example, we found an occurrence where the health care assistant used a PGD instead of a PSD which the clinical leadership was not aware of until we pointed it out during the site visit.

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. The service did not have risk assessments for some emergency medicines that were not available during the site visit.

However, following the site visit, the service shared completed risk assessments for the medicines not available such as naloxone and opiates (diamorphine, morphine, pethidine). We were also told that atropine was not available because the service did not fit intrauterine devices but they provide minor surgeries and atropine is strongly recommended to respond to any emergency during minor surgeries.

The provider had effective systems to manage and respond to safety alerts and medicine recalls. Vaccines fridges temperatures were recorded and there was a backup thermometer in the fridge. However, there was no data logger. The service informed us that there was an alarm system and a safety protocol if there was a power cut. Staff understood the protocol to follow if the temperatures were out of the recommended range.

Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring and followed up on patients that did not engage with the service to complete with required blood tests. Clinical searches completed showed that female patients on medicines used to treat seizures and bipolar needed to be informed of the risks associated with the medicine such as teratogenicity (the capacity to cause birth defects or developmental harm to an unborn baby) and ensure the actions taken are documented.

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.