Sheerness Health 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 identified two breaches of the legal regulations. People did not receive safe care. People had not had their care reviewed in line with national guidance and best practice. For example, staff failed to action test results, diagnose patients and inform them of risks to their health and well being. Medicines were not prescribed and monitored safely. Vulnerable people were not known to the practice, their care was not reviewed and risks escalated to senior clinicians if they disengaged with services.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There were no established and effective systems in place to identify risks, discuss and learn from them including embedding improvements. Clinical and non-clinical meetings were infrequent and poorly attended by clinicians and the registered manager.

There were not established and effective systems in place to safeguarding vulnerable adults and children. The appointed safeguarding lead did not effectively maintain and oversee vulnerable people in their care. Records of vulnerable people had not been appropriately flagged for the attention of staff . Clinicians did not follow up with parents of children at risk who failed to engage with services such as declining to have their children vaccinated. The practice did not hold, contribute to or attend safeguarding meetings. We checked a sample of do not attempt resuscitation records for patients and found appropriate safeguards had not been observed. The forms had not been overseen and authorised by the most senior responsible clinician overseeing the person’s care.

There were not systems and processes in place clearly defining people’s roles, responsibility and the scope of their clinical activities to ensure safe and appropriate decision making. There was no risk escalation guidance in place to assist staff to know when advice should be sought. Decisions were individual and founded on the persons judgement. Clinical team members were not provided with protected learning time for formal clinical supervision with a senior clinician to assure safe practice. Clinical meetings were not held regularly and when they were conducted, were poorly or not attended by a GP to discuss clinical matters.

We found up-to-date information about people’s medicines was not available to clinicians on the persons medical record, when they move between health and care settings.

There were not established and effective systems in place to ensure the safe prescribing, administering and monitoring of medicines. Clinical staff had administered vaccinations without appropriate authorisation in place. Some patient reviews were not up to date and high-risk medicines were not effectively monitored. There was no system in place to ensure Medical and Healthcare products Regulatory Agency alerts (providing alerts, recalls and safety information on drugs and medical devices) were recorded, reviewed and actioned. Clinical templates were not being used consistently to improve the quality of the clinical assessment, inform safe practice and alert them to potential considerations.

The practice did not effectively monitor patient outcomes to ensure safe and effective prescribing. Some clinicians failed to adhere to national guidance placing people at risk of harm. We shared our findings with the practice who sought the support of their Integrated Care Board (ICB) to review people’s care. The ICB are NHS organisations responsible for planning health services for their local population.