All inspections: Beacon Medical Practice

We carried out an announced comprehensive inspection at Beacon Medical Practice on 6 and 10 August 2021.

At our previous inspection on 20 October 2020, we rated it as inadequate for providing responsive services. It was rated as requires improvement for providing caring and well led services. It was rated as good for providing safe and effective services. It was rated as requires improvement overall. As the practice was already in Special Measures following its November 2019 inspection, it remained so.

We rated the practice as requires improvement for caring because:

Feedback from patients on NHS Choices, the CCG listening clinic and GP Patient Survey showed dissatisfaction.

We rated the practice as inadequate for providing responsive services because;

Patients reported that they found it difficult to access the service by telephone and were dissatisfied with their experience.
The practice could not demonstrate they had taken any action to address the issues.

We rated the practice as requires improvement for providing well-led services because:

The practice did not have clear and effective processes for managing risks, issues and performance.
There was limited evidence that the practice involved the public, staff and external partners to sustain high quality and sustainable care.

We undertook this inspection of this service on 6 and 10 August 2021 to see if enough improvements had been made for the practice to come out of Special Measures. We found that the issues had been addressed and the practice had made significant improvements.

We based our judgement of the quality of care at this service on a combination of:

• what we found when we inspected

• information from our ongoing monitoring of data about services and

• information from the provider, patients, the public and other organisations.

We have rated this practice as good for all key questions, good overall and good for all population groups.

The practice provided care in a way that kept patients safe and protected them from avoidable harm.
Patients received effective care and treatment that met their needs.
Staff dealt with patients with kindness and respect and involved them in decisions about their care.
The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
Patients could access care and treatment in a timely way.
The way the practice was led and managed promoted the delivery of high-quality, person-centred care.

Whilst we found no breaches of regulations, the provider should:

Record alerts regarding safeguarding on the records of parents/household adult family members of children with safeguarding concerns and on the records of all adults with safeguarding concerns.
Establish a consistent approach to monitoring and recording the temperatures of fridges used to store medicines.
Review the process and control of blank prescription stationery.
Ensure that annual long-term condition reviews are taking place now that COVID-19 restrictions are easing and put in place actions to improve QOF indicator achievements, including providing single appointments for multiple long- term condition reviews.
Ensure that where learning from concerns, complaints and significant events had been identified, evidence of its dissemination to staff was recorded.
The practice should continue to encourage cervical cancer screening and childhood immunisations.
Continue to seek patient feedback and improve satisfaction levels with the services provided.

I am taking this service out of special measures. This recognises the significant improvements that have been made to the quality of care provided by this service.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

We carried out an announced comprehensive inspection at Beacon Medical Practice on 22 October 2020.

At our previous inspection on 22 November 2019, we rated it as inadequate in safe, effective, responsive and well led. It was rated as requires improvement in caring. It was rated as inadequate overall and placed in Special Measures.

We rated the practice as inadequate for providing safe services because:

The practice did not have clear systems and processes to keep patients safe.
The practice did not have appropriate systems in place for the safe management of high-risk medicines.

We rated the practice as inadequate for providing effective services because:

Patients with some long-term conditions were not having their healthcare needs met.
Cervical cancer screening uptake was below target.
The practice had high numbers of patients who attended A&E services and high numbers of unplanned admissions to secondary care. The provider had not taken any action to address these issues.

We rated the practice as inadequate for providing responsive services because;

Patients reported that they found it difficult to access the service by telephone and were dissatisfied with their experience.
Our own analysis of appointment availability supported the premise that there were insufficient numbers of clinical appointments available.
The provider had not taken any action to address the shortfall and had reduced the number of GP appointments available.

We rated the practice as inadequate for providing well-led services because:

Leaders could not show that they had the capacity and skills to deliver high quality, sustainable care.
While the practice had a vision, that vision was not supported by a credible strategy.
The practice culture did not support high quality sustainable care.
The clinical and administrative governance arrangements were ineffective.
The practice did not have clear and effective processes for managing risks, issues and performance.
We saw little evidence of systems and processes for learning, continuous improvement and innovation.

These areas affected all population groups, so we rated all population groups as inadequate.

We rated the practice as requires improvement for caring because:

Feedback from patients on NHS Choices, the CCG listening clinic and GP Patient Survey showed dissatisfaction.

As a result of the inspection team’s findings from the inspection in November 2019, the Commission imposed a condition on the provider’s registration, that no new patients other than new born babies of current patients and looked after children were to be registered at the practice. The practice was placed into Special Measures.

We undertook a further inspection of this service on 22 October 2020 to see if enough improvements had been made for the practice to come out of Special Measures. We found that many of the issues had been addressed and the practice had made significant improvements.

We based our judgement of the quality of care at this service on a combination of:

• what we found when we inspected

• information from our ongoing monitoring of data about services and

• information from the provider, patients, the public and other organisations.

The key questions safe and effective led are now rated as good. The key questions caring, and well-led are now rated as requires improvement. The key question of responsive remains inadequate. The practice is rated as requires improvement overall and remains in Special Measures.

We rated all the population groups as inadequate as the issues relating to access to services affected all population groups.

The practice must;

Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

If, after re-inspection, the service has failed to make sufficient improvement, and is still rated as inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or varying the terms of their registration within six months if they do not improve. The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement, we will move to close the service.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

We carried out an announced comprehensive inspection at Beacon Medical Practice on 20 and 22 November 2019 as a result of concerns we had been made aware of. We had previously inspected this practice on 18 July 2018 when we rated the practice as Good overall.

We have rated this practice as inadequate overall. We have rated all the population groups as inadequate as the issues in the safe, effective, responsive and well-led key questions affected all patients. Because of our concerns we imposed conditions on the provider registration.

We based our judgement of the quality of care at this service on a combination of:

what we found when we inspected
information from our ongoing monitoring of data about services and
information from the provider, patients, the public and other organisations.

We rated the practice as inadequate for providing safe services because:

The practice did not have clear systems and processes to keep patients safe.
The practice did not have appropriate systems in place for the safe management of medicines.

We rated the practice as inadequate for providing effective services because:

Patients with some long-term conditions were not having their health care needs met.
Cervical cancer screening uptake was below target.
The practice had high numbers of patients who attended A&E services and high numbers of unplanned admissions to secondary care. The provider had not taken any action to address these issues.

We rated the practice as requires improvement for providing caring services because:

Feedback from patients on NHS Choices, the CCG listening clinic and GP Patient Survey showed dissatisfaction.

We rated the practice as inadequate for providing responsive services because:

There was patient dissatisfaction regarding access to and the number of clinical appointments available.
Our own analysis of appointment availability supported the premise that there were insufficient numbers of clinical appointments available.
The provider had not taken any action to address the shortfall and had reduced the number of GP appointments available.

We rated the practice as inadequate for providing well-led services because:

Leaders could not show that they had the capacity and skills to deliver high quality, sustainable care.
While the practice had a vision, that vision was not supported by a credible strategy.
The practice culture did not effectively support high quality sustainable care.
The overall governance arrangements were ineffective.
The practice did not have clear and effective processes for managing risks, issues and performance.

The areas where the provider must make improvements are:

Ensure that care and treatment is provided in a safe way.
Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement, we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

The practice had reviewed the process for monitoring the temperature of refrigerators used to store medicines.
The practice had taken steps to ensure patient confidentiality at the reception area.
The practice had responded to concerns over appointment availability and had introduced a ‘sit and wait’ system to meet the needs of some patients.

The areas where the provider should make improvements are:

Monitor and review the appointment system and availability.
Review and monitor patient satisfaction with the service provided.
Review the process for monitoring and regulating the temperature of the dispensary at Ingoldmells.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Beacon Medical Practice on 8 November 2017. The practice is rated as good for caring and requires improvement for safe effective, responsive and well-led. Overall the practice is rated as requires improvement.

At the last inspection on 15 July 2015 it was rated as good overall.

The key questions are rated as:

Are services safe? – Requires improvement

Are services effective? – Requires Improvement

Are services caring? – Good

Are services responsive? – Requires improvement

Are services well-led? – Requires improvement

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Requires improvement

People with long-term conditions – Requires improvement

Families, children and young people – Requires improvement

Working age people (including those retired and students – Requires improvement

People whose circumstances may make them vulnerable – Requires improvement

People experiencing poor mental health (including people with dementia) – Requires improvement.

They are rated as requires improvement because the ratings for safe, responsive, effective and well-led applied to everyone using the practice including all population groups.

At this inspection we found:

The practice had good facilities and was well equipped to treat patients and meet their needs. However the branch surgery at Chapel St Leonards was in need of replacement or substantial extension and refurbishment.
The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice identified learning but the actions from the learning was not always implemented.
The practice routinely reviewed the effectiveness and appropriateness of the care it provided. Care and treatment was delivered according to evidence- based guidelines, although leaders had not taken positive action to ensure that an un-commissioned service being undertaken at the practice was being conducted with appropriate clinical oversight or ceased.
The practice had an effective process for managing risk such as those posed by healthcare associated infections, fire and waste management.
Staff involved and treated patients with compassion, kindness, dignity and respect.
Patients we spoke with said they found it difficult to get appointments and reported that they were not able to access care when they needed it.
Feedback from patients about their interactions with nurses was positive but patients were less satisfied with their dealings with GPs.
There was no evidence of clinical audit being undertaken to help improve patient outcomes.
The processes for manging medicines posed a risk of people not always being kept safe.
The practice actively reviewed complaints and how they are managed and responded to, and made improvements as a result.
The practice worked closely with other organisations and with the local community in planning how services were provided to ensure that they meet patients’ needs. For example in their leading in anti-coagulation services for the area.

The areas where the provider must make improvements as they are in breach of regulations are:

Ensure that there is a protocol in place for obstetric ultra-sound scanning and ensure that there is clinical oversight and audit of the service provided.
The practice must ensure that learning identified as a result of significant events investigations is cascaded to all GPs and staff and that the actions are implemented.
Prescribers must consider and satisfy themselves ofthe appropriateness of issuing repeat prescriptions.
Blank prescription forms should be securely stored when not in use to prevent unauthorised access to them.
Ensure that dispensary standard operating procedure documents are correctly signed.
Patient group directives should be reviewed and updated to reflect that individual nurses are specifically authorised.
Complete clinical audits to drive quality improvement.

The areas where the provider should make improvements are:

Undertake an audit on non-clinical prescribing practice.
Remind staff that medicines should be retained in their original packaging.
Should take steps to remind reception staff of the need for patient confidentiality.
Review the procedures for monitoring the temperatures of fridges used to store medicines.
Should continue to monitor patient satisfaction with regard to appointment availability and take steps to improve access to services.
Review the arrangements in place for obstetric ultra sound scanning to ensure the procedures do not impact on clinical time to deliver the core commissioned services.

Professor Steve Field (CBE FRCP FFPH FRCGP)

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced focused inspection at Beacon Medical Practice on 15 July 2015. Overall the practice is rated as good. Specifically, we found the practice to be good for providing safe, responsive and well-led services.

We had previously inspected this practice on 6 October 2014 when we found that the practice required improvement in providing safe, responsive and well led services.

Our key findings across the areas we inspected were as follows:

The practice had implemented a system to ensure that incoming mail was dealt with in an appropriate manner to help ensure patients were safe.
There was evidence that learning from significant events and complaints was communicated to staff to support improvement.
The practice had reviewed the infection prevention and control policy which now included the need for repair or replacement of equipment to support effective infection control.
There was a clear management structure with GPs in designated lead roles.
A programme of continuous cycle audit was used to monitor quality and to make improvements.

Professor Steve Field (CBE FRCP FFPH FRCGP)

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We inspected this service on 6 October 2014 as part of our new comprehensive inspection programme.

The overall rating for this practice is requiring improvement. We found the practice to be good in the effective and caring domains and required improvement in the safe, responsive and well-led domains. We found the practice required improvement in the care they provided to the population groups of older people, people with long term conditions, working age people, people experiencing poor mental health and people in vulnerable circumstances.

.Our key findings were as follows:

The practice had started to put systems in place to provide a better service for older people, those with long term conditions and those with learning disabilities. These systems had not yet had the time to be embedded in order to judge their impact.

The practice had recognised that there was a lack of patient satisfaction with access to appointments particularly during the peak holiday season due to an increase in the number of temporary residents. There was evidence of on-going monitoring and initiatives to respond to the situation to increase appointment availability although it remained a problem at peak times of the holiday season due to an influx of temporary residents. The practice had been working with the Clinical Commissioning Group and Patient Participation Group (PPG) to address this issue.

The practice had systems, processes and policies in place to manage and monitor risks to patients, staff and visitors to the practice.

Evidence we reviewed demonstrated that most patients were satisfied with how they were treated and that this was with compassion, dignity and respect. It also demonstrated that the GPs were good at listening to patients and gave them enough time.

The practice had gone through a period of change in respect of staffing which had an impact on staff morale. It was clear from discussions with staff that morale had improved and they now felt valued and well supported.

There were areas of practice where Beacon Medical Practice needed to make improvements.

We have asked the practice to take action on three issues where we found that improvements were needed. The provider was in breach of the regulation related to assessing and monitoring the quality of service provision.

Importantly, the provider must:

Review the infection control action plan and make it more robust with respect to timescales. It should also reflect the need for repair or replacement of equipment to ensure infection prevention and control. Staff should be made aware of relevant outcomes of the infection control audit.

Have a system in place to audit the quality of data added to medical records and assess the appropriateness of a non clinical staff member having responsibility for assessing some incoming clinical information.

Have a system in place to ensure that learning from incidents and complaints is identified and disseminated to staff appropriately and widely enough.

Additionally the provider should:

Ensure that all staff are aware of who holds lead roles within the practice and the responsibilities of those roles.
Review the length of appointment slots to ensure they meet the needs of patients.

Professor Steve Field (CBE FRCP FFPH FRCGP)

Chief Inspector of General Practice

Beacon Medical Practice

All Inspections

10 August 2021

During a routine inspection

22 October 2020

During a routine inspection

22 November 2019

During a routine inspection

18 July 2018

During an inspection looking at part of the service

8 November 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

Professor Steve Field (CBE FRCP FFPH FRCGP)

15 July 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

6 October 2014

During a routine inspection

Letter from the Chief Inspector of General Practice

Professor Steve Field (CBE FRCP FFPH FRCGP)