The Care Quality Commission
  • Organisation
  • SERVICE PROVIDER

Eltham Palace PMS

This is an organisation that runs the health and social care services we inspect

Registration details

The provider ID for Eltham Palace PMS is 1-199741074.

These are the registration details of the provider Eltham Palace PMS. They set out what services Eltham Palace PMS can legally provide, where they can provide them and who is responsible for them.

Partners

Dr Esmeralda Margery Peters, Dr Jorge Manuel Vieira De Araujo Ribeiro

Maternity and midwifery services

Terms of this registration relating to carrying out this regulated activity

The registered provider must ensure that the regulated activity Maternity and midwifery services is managed by an individual who is registered as a manager in respect of that activity at or from all locations.

Registered services

Family planning

Terms of this registration relating to carrying out this regulated activity

The registered provider must ensure that the regulated activity Family planning is managed by an individual who is registered as a manager in respect of that activity at or from all locations.

Registered services

Treatment of disease, disorder or injury

Condition of this registration relating to carrying out this regulated activity

5. The Registered Provider must provide the Care Quality Commission with a report setting out the actions taken or to be taken in relation to conditions 1-4 above by 29 May 2023 and monthly thereafter. The report must also include the following:
a. details of the system(s), policy(ies) and processes that are implemented to comply with the conditions,
b. details and confirmation of action taken to ensure the system(s) are being audited and monitored to improve the quality and safety of service.

4. The Registered Provider must ensure there are sufficient daily appointments to manage the demands of and access for Service Users.

3. The Registered Provider must develop and implement policies and protocols for the management of long term conditions. These policies should be in line with recognised guidance and include the identification, escalation and management of long term conditions such as diabetes, chronic kidney disease and asthma but not limited to these.

2. The Registered Provider must develop and implement an effective system and/or process for the management of patient safety alerts in particular:
a. Coding of alerts
b. Review of alerts on patient records
c. Set timescales to action alerts.

1. The registered provider must develop and implement an effective system and/or process for the management of service users being prescribed high-risk medications. The process should include but not limited to:
a. Identification, escalation and management i.e. reviews, follow-up and/or investigations takes place, in line with recognised guidelines
b. To ensure that information about high-risk medications is correctly recorded in records to support patient safety.

Terms of this registration relating to carrying out this regulated activity

The registered provider must ensure that the regulated activity Treatment of disease, disorder or injury is managed by an individual who is registered as a manager in respect of that activity at or from all locations.

Registered services

Surgical procedures

Terms of this registration relating to carrying out this regulated activity

The registered provider must ensure that the regulated activity Surgical procedures is managed by an individual who is registered as a manager in respect of that activity at or from all locations.

Registered services

Diagnostic and screening procedures

Condition of this registration relating to carrying out this regulated activity

1.1 Within 14 days of these conditions taking effect, the Registered Provider must:
1.1.1 Develop and implement effective policies and protocols in line with recognised guidance to ensure:
1.1.1.1 Patients with long term conditions are effectively identified, monitored and managed.
1.1.1.2 Medication reviews include sufficient, appropriate information.
1.1.1.3 Periodic clinical review and audit of long term conditions, identifying any learning.
1.1.1.4 An effective system for the management of patient safety alerts.
1.1.2 Provide CQC with details of the system that has been put in place.

1.2 Within 21 days of these conditions taking effect, the registered provider
must:
1.2.1 Create a list detailing the order of priority for monitoring reviews to be
undertaken for patients who have not received a review of their long term
condition within the last 12 months.
1.2.1.1 This list must be provided to CQC within 21 days.
1.2.2 Provide CQC with evidence within 21 days which demonstrates:
1.2.2.1 How those patients have been categorised in terms of their risk, including
the rationale for this.
1.2.2.2 The total numbers of patients identified for each long term condition.
1.2.3 Provide an action plan to CQC within 21 days, which demonstrates when
patients will receive their long term condition reviews, taking into account
the order of priority.

1.3 Within 14 days of these conditions taking effect, the Registered Provider
must establish and implement an effective system to ensure all clinical and
non-clinical staff receive up-to date mandatory training, communication /
training relevant to their roles, but not limited to:
1.3.1 Information Governance training,
1.3.2 Mental Capacity Act (2005) training,
1.3.3 Confidentiality training, and
1.3.4 Safeguarding Vulnerable Adults and Children training to the relevant level
as set out in national guidance such as intercollegiate safeguarding
guidance for healthcare staff.
1.3.5 Outcomes of meetings/reviews and/or learning.

1.4 Within 21 days of these conditions taking effect, the Registered Provider
must:
1.4.1 Maintain oversight of the practice management and ensure there is
sufficient managerial capacity within the practice to ensure governance is
carried out.
1.4.2 Develop a joint leadership and governance plan that details how the
partnership will work together, utilising the support and resources available.
1.4.3 Provide CQC with details of the system that has been put in place.

1.5 Within 21 days of these conditions taking effect, the Registered Provider
must develop and implement a system to:
1.5.1 Determine the clinical and non-clinical capacity needed to meet the
requirements of Service Users safely, including but not limited to:
1.5.1.1 assessment of relevant capacity and resources, and
1.5.1.2 action taken to improve access.
1.5.2 Timely respond to Service Users, including but not limited to, medication
requests and queries.
1.5.3 Provide CQC with details of the system that has been put in place and
detail any ongoing recruitment processes if there are identified staffing
shortfalls.

1.6 On the first Monday of each month thereafter, the Registered Provider shall
report to the Care Quality Commission describing the reviewed system in
place for condition 1- 5. The report must also include the following:
1.6.1 confirmation that the system, policies are implemented and are
effective,
1.6.2 details of action taken to ensure the system, policies are being audited
monitored and continues to be followed, and
1.6.3 results of monitoring data and audits undertaken that provide assurance
that action is taken to improve the quality and safety of services.

Terms of this registration relating to carrying out this regulated activity

The registered provider must ensure that the regulated activity Diagnostic and screening procedures is managed by an individual who is registered as a manager in respect of that activity at or from all locations.

Registered services