The Care Quality Commission
  • Doctor
  • GP practice

Beacon Medical

Overall: Good read more about inspection ratings

St Hughs Avenue, Cleethorpes, Lincolnshire, DN35 8EB (01472) 691033

Provided and run by:
Beacon Medical

All Inspections

14 and 19 July 2022

During an inspection looking at part of the service

We carried out an announced inspection at Beacon Medical on 14 and 19 July 2022. Overall, the practice is rated as Good.

Set out the ratings for each key question

Safe - Requires Improvement

Effective – Good

Responsive - Inspected but not rated

Well-led - Good

Following our previous inspection on 12 February 2019, the practice was rated Good overall and for all key questions. We did not inspect the caring domain and inspected access under the responsive domain, but did not rate, so they remain rated as Good

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Beacon Medical on our website at www.cqc.org.uk

Why we carried out this inspection

This was a focused inspection conducted as part of the national sampling programme of services rated good or outstanding who have undergone remote monitoring assessment.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Conducting staff interviews using video conferencing
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider
  • Reviewing patient records to identify issues and clarify actions taken by the provider
  • Requesting evidence from the provider
  • A short site visit

Our findings

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 Requires Improvement overall

We found that:

  • The practice had not always provided care in a way that kept patients safe and protected them from avoidable harm because recruitment policies were not always fully implemented and there were some gaps in aspects of the safe management of medicines and liquid nitrogen.
  • Patients received effective care and treatment that met their needs.
  • Staff treated 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 leadership team demonstrated an open and transparent leadership style.
  • The way the practice was led and managed promoted the delivery of high-quality, person centred care. However, areas of the practice were not managed consistently as concerns in relation to risk management identified during the inspection had not been identified or resolved by the practice.

We found an area of outstanding practice:

  • In recognition for their work during the pandemic to provide vaccinations for 60,000 patients across multiple primary care networks (PCN’s), the practice was awarded an NHS Hidden Heroes Award in 2021 for outstanding service during the pandemic.

We found one breach of regulations. The provider must:

  • Ensure care and treatment is provided in a safe way to patients.

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

  • Implement the new recruitment checklist and complete the audit of staff recruitment records to identify shortfalls and request any outstanding records.
  • Continue to encourage patient uptake in cervical cancer screening.
  • Continue to recruit new members for the patient participation group to involve patients in the running of the practice.
  • Continue to replace the high-risk areas of flooring.
  • Continue to complete the improvement works planned in the fire and Legionella risk assessments.

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

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services

12/02/2019

During a routine inspection

We carried out an announced comprehensive inspection at Beacon Medical on 12 February 2019 as part of our inspection programme.

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 previously inspected the practice on 12 May 2016. We found the practice was Good overall and Requires Improvement for providing Safe services. We said the practice must put in place a system to manage the implementation of national medicines and safety alerts and ensure recruitment procedures and policy is followed and arrangements include all necessary employment checks for all staff. At the inspection on 12 February 2019 we found this was satisfactory.

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

We found that:

  • 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 organised and delivered services to meet patients’ needs. 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-centre care.

The area where the provider should make improvement are:

  • Continue to monitor the documented management of test results is working.
  • Improving the identification of carers that are registered at the practice.

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

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

12 May 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Beacon Medical on 12 May 2016. Overall the practice is rated as good.

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients were assessed and managed, with the exception of those relating to recruitment checks.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • When things went wrong reviews and investigations were not thorough enough and lessons learned were not communicated widely enough to support improvement.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Data showed patient outcomes were similar compared to the national average. Although some audits had been carried out, we saw no evidence that audits were driving improvements to patient outcomes.
  • Information about services and how to complain was available on the website and easy to understand. Some improvements were made to the quality of care as a result of complaints and concerns.
  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the duty of candour.
  • The practice had a number of policies and procedures to govern activity.

The areas where the provider must make improvement are:

  • Put in place a procedure to manage the implementation national medicines and safety alerts within the practice.
  • Ensure recruitment procedures and policy is followed and arrangements include all necessary employment checks for all staff.

The areas where the provider should make improvement are:

  • Improving the identification of carers that are registered at the practice
  • Carry out two-cycle clinical audits to improve patient outcomes.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice