Benfield Park Medical Group

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 good. At this assessment, the rating has changed to Requires Improvement.
The service was in breach of legal regulation in relation to Safe Care and Treatment.

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 service demonstrated a learning culture which actively supported the delivery of safe care. Staff were encouraged to report incidents, near misses, and safety concerns, and they understood the importance of learning from these events. Significant Event Analyses (SEAs) were completed where appropriate, enabling the team to reflect on incidents, identify contributory factors, and implement changes to reduce future risks.
Learning from incidents, complaints, and safety events was routinely shared through staff meetings. This included discussing cases of concern, reviewing areas of positive practice, and highlighting opportunities for improvement. Staff described an open and supportive environment where they felt comfortable raising issues and contributing to learning discussions.
The service actively encouraged patient feedback to support continuous learning. Feedback was gathered through the Friends and Family Test (FFT), direct verbal and written feedback to staff, and structured engagement with the Patient Participation Group (PPG). The service used learning effectively to embed improvements and strengthen safety systems. When things went wrong, staff apologised and offered support to those affected, and actions were taken to prevent recurrence. Overall, the service demonstrated a clear commitment to ongoing improvement.

The service worked with people and healthcare partners to maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. There were systems in place for processing information relating to new patients. The service worked with other providers to deliver shared care and support transition when patients moved between services. Processes where in place to manage referrals and test results.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.
Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations.

The service worked with people to understand and manage risks in a holistic way. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.
Emergency equipment was available and maintained. Staff could recognise a deteriorating patient and knew of action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated. However, remote clinical searches identified concerns in the management of some long‑term conditions, including some overdue reviews.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.
Arrangements were in place with the building owners to ensure the premises were compliant with relevant regulations and were appropriately cleaned and maintained. We saw evidence that health and safety risk assessments and audits had been completed, and any identified risks were addressed in a timely manner.
A business continuity plan was in place, setting out how the service would continue to operate during emergencies or disruptions. This plan was routinely monitored and regularly updated to ensure it remained current and effective.
 

When we inspected this service, we found that most mandatory training was up to date. However, there were gaps in learning disability training; several staff members were either not enrolled or had not yet started this module. Learning disability training is a legal requirement, and the lack of completion presents a compliance risk. While most staff were working within their defined areas of competence, we also found some instances where staff with clerical access to the electronic patient record system were entering clinical coded information, which was outside the scope of their role. We saw evidence that staff received regular supervision, and some had been supported to access additional training beyond the mandatory requirements, which they were applying in their roles. We also saw evidence that safe recruitment procedures were being followed.

The service had effective systems in place to assess and manage the risk of infection. Staff were able to identify and control infection risks and appropriately escalated concerns to relevant external agencies when required. The practice had a designated lead for infection prevention and control. Risk assessments and audits were routinely completed, with actions taken to address identified issues and reduce risks. All staff had completed relevant infection prevention and control training. Cleaning services were provided by an external contractor, and documented cleaning schedules were in place and being followed.

The service did not always have effective systems in place to ensure medicines and treatments were managed safely. Clinical searches and record reviews showed some gaps in the monitoring and oversight of high‑risk and long‑term medicines. Monitoring for disease‑modifying anti‑rheumatic drugs (DMARDs) was inconsistent, follow up to safety alerts were missing, essential MHRA dosing instructions were not always recorded, and some patients lacked required blood test checks.
We also identified risks in the management of heart‑failure medicines. Patients continued to receive repeat prescriptions despite overdue monitoring, including one high‑risk patient three years overdue essential tests. Blood‑pressure checks for some within this patient group were not completed, and medication reviews failed to identify missed monitoring or abnormal results.
Medication reviews across several drug groups, including gabapentinoids, were often code‑only entries with no evidence of clinical assessment. This meant there was no record of the practice reviewing any side effects, effectiveness, dependency risk, and appropriateness of ongoing treatment. We identified further concerns in asthma, hypothyroidism, and diabetes care, including incorrect steroid dosing, incomplete documentation, overdue monitoring, lack of follow‑up of abnormal results, and inappropriate coding by non‑clinical staff.
Although the practice kept prescription pads in a lockable room, there were no formal processes or audits in place to ensure accountability or track their use. Medicines were otherwise stored securely, with correct temperature monitoring, stock checks, and expiry checks.

After the assessment, the provider sent us information to tell us about the improvements they had made and were making.