Belvidere Medical Practice

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 people were protected from abuse and avoidable harm. At our last assessment, we rated this key question as good. At this assessment, the rating remains the same.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

The service mostly detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The service had contracts to ensure the premises was maintained. Staff and leaders completed health and safety risk assessments and undertook audits to ensure they had identified and addressed risks. However, we found that not all potential risks had been identified and assessed. For example, unlocked vacant consultation rooms, cleaning products held in an unlocked cupboard, window blinds which posed a potential strangulation hazard, a portable electrical fan and a waiting area without direct staff oversight.

The service had a business continuity plan which was regularly reviewed and outlined how the service should continue to operate in the event of a disruption. The practice had systems for tracking prescription stationery; however access was not currently restricted to authorised individuals.

Following our site visit the Provider confirmed they had reviewed all of the potential risks we identified and had taken steps to address and mitigate the risks in the safety of people using the service and staff.

The service had experienced significant workforce changes in the previous 6 months. This included changes in the GP Partnership, salaried GPs, nursing and reception teams. Leaders and staff we spoke with considered there was now enough qualified, skilled and experienced staff employed to meet patient expectations.

The service employed a range of clinical and non-clinical roles. In addition, the service utilised staff employed through their local Primary Care Network, providing a broader range of services to patients. This included a cancer care co-ordinator, social prescriber, mental health facilitator, paramedics and pharmacists. A dementia care co-ordinator was shortly due to join the team.

Leaders ensured staff were up to date with their training which the service had deemed mandatory and operated within their agreed areas of competence. Staff told us they received support, supervision and learning and development opportunities. They worked together well to provide safe care that met people’s individual needs.

Staff told us they received regular appraisals and leaders supported them to access training appropriate to their role. For example, the lead nurse for infection control and prevention (IPC) had attended a 2-day IPC course to support them in their role.

The service utilised their Primary Care Network (PCN) to carry out recruitment checks for new staff employed at the practice. At the time of our site visit, not all of the relevant pre-recruitment checks for the staff we reviewed were held at the practice as required. However, these were obtained from the PCN during our site visit with the exception of health declarations for 2 of the 4 staff records we reviewed. In addition, there was not always a full immunisation history, or risk assessment of staff vaccinations against potential healthcare acquired infections. Following our site visit leaders told us they would be holding ongoing discussions with the PCN with regards to the pre-recruitment checks to ensure all documentation is made available and any gaps highlighted to them for action, as appropriate.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service’s infection prevention and control (IPC) lead nurse had attended a designated IPC lead training course arranged through their Primary Care Network (PCN) to equip them with the knowledge and skills to support them in their role. Discussions with them demonstrated they had a clear understanding of their role and responsibilities.

The service commissioned an external cleaning company and in conjunction with them regular risk assessments and audits were undertaken to ensure compliance. Action was taken where necessary to mitigate any identified risks. Staff had completed relevant training in infection prevention and control.

Cleaning schedules were available and outlined how staff should clean the building and its equipment. The service demonstrated how these were monitored for completion to maintain oversight of cleaning arrangements. During our onsite visit, areas of the premises and a sample of equipment we reviewed was noted to be visibly clean.

Patients we spoke with during our site visit told us they were satisfied with the cleanliness and hygiene standards of the practice.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.