The Bethesda Medical 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 looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment, we rated this key question as requires improvement. At this assessment, the ratingremains as requires improvement.

The practice did not have established and effective systems in place to keep vulnerable children and adults safe. Improvements were required in the management of medicines for some long-term health conditions.

People were encouraged to raise concerns and the service learnt from these. Managers investigated incidents thoroughly. Staff understood and managed risks relating to their environment and storage of medicines. The facilities and equipment met the needs of people, were clean and well-maintained and any risks were mitigated. There were enough staff with the right skills, qualifications and experience. Managers made sure staff received training and regular appraisals.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice had established and effective systems in place to identify, capture, investigate and learn from complaints and incidents. We found risks were not consistently revisited to ensure they were sufficiently mitigated or removed. The provider acknowledged this and was strengthening their systems.

Staff knew how to raise concerns and told us they were supported to do so. They believed leaders and colleagues were committed to investigating and resolving them. Where improvements were required, information, advice and guidance were shared amongst staff to improve the safety and standards of care.

Staff were trained in identifying and reporting concerns and had a designated lead member of staff should they wish to speak with someone directly.

There were established and effective systems in place to listen, engage and work with people and their partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. The provider actively monitored referrals, admissions and discharges from services. Patient records correctly detailed prescriptions issued by secondary care.

Staff monitored people’s progress along care pathways to identify barriers to accessing and maintaining care, escalated risks to partnership forums for resolution where appropriate. We found there were systems in place to support people as they moved between services. Clinical meetings were well attended by a broad range of clinicians and held frequently. We found there was a collaborative, joined-up approach to people’s care.

The practice did not have established effective systems in place to safeguard vulnerable adults and children. The practice did not check the accuracy of their safeguarding registers, family members (parents and siblings) and carers were not always identified on the system. Records lacked details of who had parental responsibility for children who had been identified as vulnerable. We found some vulnerable children’s needs had failed to be considered and met. We saw children had not been appropriately followed up with when they failed to attend appointments with primary and or secondary care services. A safeguarding lead was appointed but they were unclear on their role and responsibilities. Safeguarding meetings were held but records failed to reflect risks and actions taken.

Staff were trained in safeguarding and they understood, applied and adhered to the Gillick competency (often used to assess whether a child is mature enough to consent to treatment), Fraser guidelines (used specifically for children requesting contraceptive or sexual health advice and treatment) and the Mental Capacity Act.

The practice had a specialist frailty team who identified and supported vulnerable patients to coordinate and access services. Appropriate systems and safeguards were in place for do not attempt resuscitation records. The practice had sought support to improve their systems and processes.

There were established and effective processes in place to support the early recognition and timely response to risks.

People told us they were involved in decisions relating to their care. Staff were supportive when communicating their needs, emotions or distress. They were supported to identify and respond to changes in their health.

Staff identified people who may benefit from additional support and worked with them to understand, manage and mitigate risks to them. They coordinated care and support to enable people to do things that mattered to them. People were signposted to support services whilst respecting the choices they made relating to their personal care.

We found the practice was safe and well maintained. There were established and effective systems in place to identify, manage and mitigate risks to people. For example, the practice had conducted environmental risk assessments (including legionella testing and portable appliance testing) to ensure staff and people were safe and revised them annually or more frequently in response to changes. Maintenance contracts were in place to maintain the accuracy of equipment (calibration), scheduled safety checks were conducted on the fire alarm system, emergency lighting and equipment. Staff had been Disclosure and Barring Service checked (a way for employers check your criminal record, to help decide whether you are a suitable person to work for them) or risk assessed.

We found there was assisted entry into the practice and a lift for access to other floors. People had access to chairs with arms in the waiting areas to assist those with limited mobility. There were appropriate baby changing facilities with appropriate restraint belt to mitigate the risk of the child falling whilst being changed. Health and safety posters were displayed in the staff only areas with contacts of who to escalate concerns to. Staff had undertaken annual training in health and safety and practices procedures. We saw fire safety wardens were trained and on duty and staff were aware of evacuation procedures and had rehearsed them. Clinical staff had been trained in emergency first aid and life support. Information was displayed throughout the practice and on their website promoting dignity and respect to people and the standards of conduct expected. Staff could alert colleagues to concerns such as verbal or physical abuse whilst providing care or support to patients.

Staff and leaders understood the recruitment, disciplinary and capability processes and believed they were fair. The management team ensured they were applied appropriately to ensure there were no disadvantages based on any specific protected equality characteristic. Staff told us appropriate staffing levels and skill mix was maintained to make sure people received consistently safe, good quality care that met their needs. Staff told us they found supervisions supportive and had professional development opportunities.

We found safe recruitment practices were employed when appointing clinical and non-clinical staff, including agency/locum staff. Staff had suitable experience or were supported and assessed as competent to carry out their role. Staff were required to complete mandatory training and had opportunities to complete further training relevant to their role. Staff performance and conduct was monitored, and poor performance was addressed. This was achieved through supervision, appraisal and support to develop and where needed, ensuring clinical staff maintained their professional revalidation. Thereby, providing greater assurance to patients and the public, employers and other healthcare professionals that licensed clinicians were up-to-date and fit to practise.

There were established and effective systems in place for identifying, assessing and managing the risk of infection, which was in line with current relevant national guidance. Staff told us they had been appropriately vaccinated to mitigate the risk to them and others of infection. They received training in infection prevention control.. They had access to barrier controls and gloves, aprons and masks to mitigate the risk of infection to people. Clinical staff used single use items and had access to body fluid spillage kits to mitigate the risk of infection to patients. Staff explained to us how they triaged and managed patients with potentially contagious diseases. The lead nurse conducted an annual infection prevention control audit and produced an annual statement.

We found the surgery to be clean and tidy and cleaning schedules in place. The reception desk was high and had clear screens to mitigate risks of infection to staff. We found all handwash dispensers were full and there were appropriate hand drying arrangements in place. We checked cleaning cupboards and found all cleaning items had appropriate processes in place to control substances hazardous to people’s health.

Risks associated with some medications had not been appropriately monitored or mitigated. This was immediately addressed by the provider: patients were contacted, and appropriate clinical actions taken.

A lead GP oversaw the management of medicines. There were systems in place to periodically search prescribing practices to identify potential risks to patients.

Patient on high-risk medicines were effectively monitored. Medicines and Healthcare products Regulatory Agency alerts (providing alerts, recalls and safety information on medicines and medical devices) were reviewed and actioned. Clinical templates were utilised by staff to improve the quality of the clinical assessment, inform safe practice and alert them to potential considerations within the practice to ensure safe prescribing practices. Best practice and guidance were shared with staff during clinical meetings to promote best practice.

Medicines were stored appropriately in accordance with cold chain procedures to maintain their integrity. We found up-to-date information about people’s medicines was available, particularly when they moved between health and care settings. People were involved with assessments and reviews about the level of support they needed to manage their medicines safely and to make sure their preferences were included. Patient reviews were up to date, and we found regular appointments were scheduled with patients with long term conditions to monitor their conditions. People were signposted to additional support services to help them with their condition, for example, dietary or smoking cessation.