Balaam Street Surgery

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.

This is the first inspection for this service since its registration with CQC. This key question has been rated as good.

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.

The service demonstrated a proactive and positive safety culture, based on openness and honesty. Concerns about safety were listened to, investigated and reported appropriately. Lessons were consistently learned to support ongoing improvement and embed good practice.

People felt confident to raise concerns and described leaders at the practice as compassionate and understanding. Representatives from the Patient Participation Group (PPG) felt the provider took concerns seriously and proactively made improvements to the service. Leaders encouraged staff to report issues, labelling incidents as learning events rather than individual failings, and promoted shared learning to improve care.

Clinical assessment policies were created and updated routinely, and clinical incidents were reviewed by lead clinicians to ensure sufficient detail was captured. There were clear processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints, and we were shown evidence of compassion and support towards patients when things went wrong.

The service worked collaboratively with people using the service and healthcare partners to establish and maintain safe systems of care.

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, ensuring continuity of care. Referrals and test results were managed in a timely way.

The service regularly engaged in multi-disciplinary meetings to review and plan care for patients with complex conditions or those nearing the end of life. This included discussions with their Primary Care Network, carers events and multi-disciplinary meetings with diabetic consultants.

The service took active steps to safeguard people from the risk of abuse, working closely with partner agencies when necessary. They maintained systems and processes to respond appropriately when staff suspected someone might be at risk of abuse or neglect. All staff members who we spoke to demonstrated an understanding of how to report safeguarding concerns and were able to identify who safeguarding leads. All staff members had completed relevant safeguarding training.

The service held regular multi-disciplinary meetings to discuss safeguarding concerns. Safeguarding policies were in place and accessible to staff. The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations.

The service held multiple safeguarding registers. Senior leaders at the practice took ownership for the transition of older children on the safeguarding register with planned, age-appropriate conversations. This included enhanced health checks supported by confidential consultations. We found the provider did not always update their safeguarding registers but responded immediately to ensure additional processes were in place so registers had frequent updates.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Shared decision-making was encouraged and facilitated through care plans and communication tools.

Emergency equipment was available and maintained. Staff could recognise a deteriorating patient and knew of what action to take. Leaders at the practice emphasised the importance of sepsis awareness to both clinical and non-clinical staff. 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.

Contracts were in place to ensure the premises were maintained. Health and safety risk assessments and audits had been undertaken and risks identified had been addressed. There was a business continuity plan in place to provide guidance in the event of a major disruption to the service, such as an IT failure or flood.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. Consultations were routinely audited and staff had support in daily debriefs. Leaders held supervisory roles to guide and audit clinical staff members. They worked together well to provide safe care that met people’s individual needs.

There were a range of clinical and non-clinical roles within the practice. We found training was up to date, learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence.

We reviewed a sample of recruitment records and found that staff were recruited safely with appropriate procedures being followed, such as DBS checks and collecting references.

Premises were clean and well-equipped to support effective infection prevention and control. The service detected and controlled the risk of infection spreading and shared concerns with appropriate agencies promptly.

There was a designated infection, prevention and control lead and all staff had completed relevant training. Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions were taken to mitigate risks.

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.

Our review of records showed that people taking medicines with specific risks that required monitoring were appropriately monitored before their medicines were prescribed. Regular medicine reviews, including for high-risk drugs, were carried out for people who used the service to ensure their medicines were safe and appropriate to their needs.

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.

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. 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.

From our review of clinical records, the provider had effective systems to manage and respond to safety alerts and medicine recalls. The practice maintained a drug safety alert list which was accessible to all staff.