Beacon Primary Care

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

Our rating for this key question is good overall. Managers investigated all reported incidents to reduce the likelihood of them happening again. Staff supported people to live healthy lives and provided them with support and information on their care and treatment. However, our clinical searches identified there were some areas where action was needed to be taken to ensure best practice was followed.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People had no specific feedback on this area.

Practice leaders informed us that the practice had a duty of candour and a freedom to speak up policy in place. We were advised that the freedom to speak up guardian from the local medical council had retired and there was no named freedom to speak up guardian in place for the practice at the time of our assessment. In the meantime, a wellbeing leader employed by the practice was acting as a point of contact for staff. Practice leaders also told us that policies and procedures were available on the practice’s shared drive for staff to access and that staff were supported to familiarise themselves with policies and guidance as part of their induction training. They informed us that the practice operated an open-door policy, and that staff were encouraged to raise concerns, so they could be supported without fear or detriment. Feedback received from staff confirmed they understood how to identify and report concerns, safety incidents and near misses and that the practice shared incidents, significant events and learning with them. Practice leaders spoken with demonstrated a commitment to learning from incidents and complaints to ensure the delivery of improved care for others and continuous improvement.

The provider had developed internal policies and procedures to provide guidance for staff on the management of incidents, safety alerts, near misses and significant events. Policies and procedures had also been established to ensure complaints were recorded, investigated and responded to within appropriate timescales. Information on how to raise a complaint was available within the practice and displayed on the practice website for patients to reference. We viewed a summary of significant event records that evidenced how significant events were managed by the practice. Records showed events had been logged, investigated and learning shared. Staff were supported to identify their training needs and protected learning time was provided for them to undertake training, learning and professional development. This was within the service and through attendance at educational events.

People had no specific feedback on this area.

Practice leaders and clinical staff spoken with demonstrated a sound awareness of referral pathways, a commitment to developing effective networks and working in partnership with other services. Likewise, staff spoken with were able to explain their roles and responsibilities in relation to workflow, call and recall, urgent referrals, summarising of new patient records, triage processes, the management of appointments and the management of incoming pathology results.

Partners had no specific feedback on this area.

The provider had developed a shared care agreement policy to ensure appropriate care and treatment was provided to patients when there was shared responsibility for their care and treatment. Clinicians followed care and treatment pathways for treating and referring people to other services. The provider worked with people who used the service and other agencies to ensure safe systems of care and treatment when people were being supported by other services. Regular multi-disciplinary meetings were held between the service and other health and social care professionals. This provided an opportunity to discuss and plan for the diverse and complex needs of the patient population including people approaching the end of their life. Systems had been established to ensure referrals to secondary or specialist care were made promptly, and people referred under the two week wait rule for suspected cancer were routinely monitored and followed up; to check they had undergone the required investigations. Reception staff had been trained in care navigation to direct people to the most appropriate service or services to meet their presenting needs. This included specialist statutory or community services and local health and wellbeing services.

People had no specific feedback on this area.

Staff informed us that they had completed safeguarding training for adults and children at a level appropriate to their role and responsibilities. Feedback confirmed staff understood who the responsible lead for safeguarding was in the practice and that they had a clear understanding of safeguarding and how to respond to suspicion or evidence of abuse.

Partners had no specific feedback on this area.

The provider had developed whistleblowing and adult and children safeguarding policies, procedures and practices to ensure an appropriate response to evidence or suspicion of abuse or neglect. Training records viewed confirmed leaders, clinicians and staff had completed safeguarding training at a level appropriate to their role and responsibilities to help them recognise, raise alerts and manage safeguarding concerns. Staff worked in a collaborative way with system partners and attended routine multi-disciplinary / safeguarding meetings to share and receive information. The practice maintained registers of vulnerable patients and key information was available to clinicians via the practice clinical system. The provider held a register of people for whom there was a safeguarding concern, and this was reviewed and updated on a regular basis. Alerts were added to the patient record system when a person was subject to safeguarding concerns so that all relevant members of the team could readily identify concerns. Systems were in place to ensure staff were appropriate to work in the service. Recruitment checks had been carried out prior to employment and all staff had been required to show proof of an up-to-date Disclosure and Barring Service (DBS) check at the required level.

People had no specific feedback on this area.

The provider shared background information during the assessment and offered an overview of some of the challenges the practice team had experienced over the last 18 months to provide contextual information for the assessment. This included the decision to register as a single-handed provider and the rationale for introducing a programme of transformation and continuous improvement. For example, the introduction of a total triage model to improve primary care access in response to the growing demand for appointments within available resources and a range of quality improvement initiatives and audits to monitor the safety and effectiveness of the care provided.

The provider had developed a dynamic recovery plan for the service which broadly outlined a range of key areas focussing on patient facing services; staff wellbeing; specific improvement projects for clinical areas; chronic disease management; population health management; workforce, leadership and succession and buildings and estates. A range of guidance, flowcharts and supporting policies and procedures had been developed to provide guidance for staff on internal processes which were subject to ongoing monitoring and review. This included information on the triage process, how to recognise and handle clinical emergencies and safety netting processes.

Staff informed us that they were satisfied with the health and safety arrangements in the practice and confirmed they had completed training in areas such as fire training and infection, prevention and control. They also confirmed they had the equipment required to perform their roles. One employee highlighted concerns regarding the suitability of room 10 at Hillside Health Centre as they reported there was no natural light or fresh air. The practice was unable to have an input into which rooms were allocated.

The main practice at Sandy Lane Health Centre was maintained by NHS property services. There were disabled access parking spaces outside of the practice and the premises was accessible via a ramp and automatic doors. The waiting area was clean and appropriately furnished, there was information for patients to view and a hearing loop was installed at the reception desk. A disabled access toilet which was equipped with baby changing facilities was also available for people to access. Facilities, services and equipment were serviced, maintained and supported to enable staff to deliver safe care and treatment. Areas viewed during the site visit including clinical rooms appeared clean and hygienic and contained the appropriate facilities to support infection, prevention and control.

The provider had developed policies on key areas such as health and safety, fire safety and business continuity and disaster recovery. A risk register for the practice together with fire and legionella risk assessments had also been completed. Action plans had been developed where applicable and supporting evidence received from the provider confirmed findings had been kept under review and acted upon. There were effective arrangements to monitor the safety and upkeep of the premises. For example, we were provided with a range of evidence that confirmed regular checks, servicing and /or calibration was carried out on the premises, facilities and equipment on an ongoing basis within the practice such as electrical wiring, portable appliances, gas safety checks and clinical equipment. Staff had been provided with training in health and safety related topics such as fire safety, moving and handling, infection control, waste management and safety in primary care.

People had no specific feedback on this area.

Overall, feedback from staff confirmed their views were listened to and acted upon by practice leaders who made efforts to support and improve working conditions for staff. For example, some staff reported that their workload was high but indicated that practice leaders listened and took action when necessary to try and address this pressure and had recruited additional staff. Staff informed us that leaders were visible, helpful and supportive with personal matters. They confirmed they had access to supervision and appraisals and had completed a range of internal and external training to help them understand their role and responsibilities. Staff were supported to keep up to date with training and their continuous professional development.

The provider had developed a policy on recruitment. We looked at the recruitment records for a sample of staff. These showed recruitment practices were carried out in line with legal requirements. All new staff underwent an induction programme and were required to undertake mandatory training within an appropriate timescale. A staff wellbeing survey had been completed during April 2024 following which an action plan had been developed by the provider.

People had no specific feedback on this area.

Staff confirmed they were provided with annual training in infection control at level 1 or 2 and that they knew who the infection control lead was for the service. Practice leaders informed us that staff had access to an occupational health service and that there had been no sharps injuries in the last year.

People who used the service were protected from the risk of infection because the premises and equipment were kept clean and hygienic. Personal protective equipment was in good supply and located appropriately around the premises. Cleaning schedules were in place and cleaning audits were carried out on a regular basis. Cleaning equipment was stored securely and in line with best practice. We noted at Railway Road surgery that room 8 (a clinical room) was fitted with a sink that had a plastic plug on a chain for the sink. This had not been highlighted on the infection prevention and control audit. We highlighted this to a member of staff so that action could be taken to address this finding.

The provider had developed an infection, prevention and control policy to provide guidance to staff on safe working practices and to help prevent and control the risk of infection. Staff had also been provided with training in infection prevention and control to help them understand their roles and responsibilities. There was a dedicated infection control lead for the practice and infection prevention and control audits were carried out periodically in addition hand hygiene audits. A centralised action plan was completed following the completion of these audits which identified any actions, target dates for completion and persons responsible. Records of staff immunisation status were maintained, and additional regular audits were carried out specifically related to minor surgery procedures. There were appropriate arrangements in place for the management and removal of clinical waste for the practice and branch sites.

People had no specific feedback on this area.

Staff confirmed they had access to medicines management policies and procedures and demonstrated a sound understanding of how they managed central alerting system patient safety alerts. The Central Alerting System (CAS) is a web-based cascading system for issuing patient safety alerts. Staff highlighted that further worked needed to be completed regarding the follow-up of clinicians who may not have acknowledged receipt of an alert(s). This was work in progress at the time of our assessment.

During our on-site assessment we saw that medicines, including vaccines were stored safely. Staff were aware of what to do if a fridge temperature was out of range and they had access to emergency medicines at each site including oxygen and a defibrillator. These were regularly checked for stock availability and to ensure they were in date. We noted that the practice did not hold all of the recommended emergency medicines, however the provider had completed a risk assessment for emergency drugs not stocked. Patient Group Directions (PGDs) (written instructions to supply or administer medicines to patients in planned circumstances for example vaccinations) were in good order and correctly dated and authorised. Prescriptions were held securely however records relating to the receipt and distribution of prescription stationary i.e. prescription forms were found to be in need of review to ensure a clearer audit trail. Action was taken to address this finding during our assessment, to ensure there was an improved process for monitoring the serial number range of prescription forms received and for tracking the distribution and return to stock of prescription forms.

The provider had systems in place to manage and respond to safety alerts and medicine recalls. A range of supporting policies and procedures had been developed to provide guidance to clinical staff. For example, in relation to prescribing, repeat prescribing and dispensing, non-medical prescribing and structured medication reviews. We noted that the majority of prescriptions were sent electronically to people’s dedicated pharmacist. Staff managed medicines-related stationary appropriately and securely. Staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely. Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring.

As part of the assessment a number of set clinical record searches were undertaken by a CQC GP specialist adviser remotely. The records of patients prescribed certain high-risk medicines were checked to ensure the required monitoring was taking place. These searches were visible to the practice. Our review showed there were some areas where action was needed to be taken. For example, in relation to Gabapentinoid prescribing. This medicine is used to treat epilepsy. It's also taken for nerve pain, which can be caused by different conditions, including diabetes and shingles. Clinical searches identified that 327 out of 584 patients may not have had a review in the last 12 months. We sampled 5 patient records and found that all 5 patients were overdue their annual medication review. Additionally, in relation to the prescribing of angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs). These are medicines used to treat high blood pressure, and heart and kidney problems. Clinical searches identified that 87 patients out of 1095 patients may not have had the required monitoring. We sampled 5 patient records and found that 1 patient had received several blood pressure reviews but no blood tests. We found that 2 patients had been recalled but had not been seen. Insight data available to CQC at the time of our assessment confirmed that overall, staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes including antibiotics. Prescribing data for the practice showed no particular variation when compared to national averages except for people prescribed Pregabalin or Gabapentin, which were slightly higher than the average.