The Bacon Lane 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.

At our last inspection in July 2023, we rated this key question as Requires improvement. At this assessment, the rating has changed, and we rated this key question 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 practice had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. Representatives from the Patient Participation Group (PPG) felt the provider took concerns seriously and proactively made improvements to the service. Managers encouraged staff to raise concerns when things went wrong. During staff meetings, the whole team discussed and learnt from clinical issues. Staff felt there was an open culture, and that safety was a top priority. The provider had processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints, and when things went wrong staff apologised and gave people support. Lessons learned from complaints, significant events were shared with staff during staff meetings and minutes of such meetings shared with all staff electronically. For example, the practice investigated an incident which involved a blood test result being sent to the wrong patient due to an incorrect email being entered in the patient’s record. The practice implemented necessary actions, reminded staff to double check the information and advised staff to share the blood test results via the clinical software.

The practice worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They ensured that there was continuity of care and patient records were updated to reflect changing needs.

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. Referrals and test results were managed in a timely way.

The practice 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 and worked in partnership with other organisations such as the local safeguarding board.

The practice 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.

Emergency equipment was available and maintained. The practice was equipped to respond to medical emergencies (including suspected sepsis) and staff were suitably trained in emergency procedures.

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.

The practice had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. Representatives from the Patient Participation Group (PPG) felt the provider took concerns seriously and proactively made improvements to the service. Managers encouraged staff to raise concerns when things went wrong. During staff meetings, the whole team discussed and learnt from clinical issues. Staff felt there was an open culture, and that safety was a top priority. The provider had processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints, and when things went wrong staff apologised and gave people support. Lessons learned from complaints, significant events were shared with staff during staff meetings and minutes of such meetings shared with all staff electronically. For example, the practice investigated an incident which involved a blood test result being sent to the wrong patient due to an incorrect email being entered in the patient’s record. The practice implemented necessary actions, reminded staff to double check the information and advised staff to share the blood test results via the clinical software.

The practice made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development opportunities. The staff worked together well to provide safe care that met people’s individual needs.

The organisation, structure and roles were clearly defined. The practice had a range of clinical and non-clinical roles. We found staff training was up to date. Learning needs and development of staff were managed well with staff working within their area of competencies.

Recruitment checks were carried out in accordance with regulations. We reviewed two staff files and found that appropriate recruitment checks had been undertaken prior to employment.

Staff who acted as chaperones were trained for their role and had received a Disclosure and Barring Service check (DBS check). (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable). All clinical staff had received an ‘enhanced’ DBS check.

The practice had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. Representatives from the Patient Participation Group (PPG) felt the provider took concerns seriously and proactively made improvements to the service. Managers encouraged staff to raise concerns when things went wrong. During staff meetings, the whole team discussed and learnt from clinical issues. Staff felt there was an open culture, and that safety was a top priority. The provider had processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints, and when things went wrong staff apologised and gave people support. Lessons learned from complaints, significant events were shared with staff during staff meetings and minutes of such meetings shared with all staff electronically. For example, the practice investigated an incident which involved a blood test result being sent to the wrong patient due to an incorrect email being entered in the patient’s record. The practice implemented necessary actions, reminded staff to double check the information and advised staff to share the blood test results via the clinical software.

The practice 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 clinical records searches showed that the practice had an effective process for monitoring patients’ health in relation to the use of medicines including medicines that require ongoing monitoring.

Staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely. People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms. 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. We found that blank prescription boxes and handwritten prescription pads were stored securely in locked cabinets. We noted the serial numbers were recorded.

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.

The provider had effective systems to manage and respond to safety alerts and medicine recalls. For example, we identified a need to ensure female patients on valproates were informed of the side effects on their reproductive health to make an informed choice on their decisions.

Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring. 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.