Bevan Medical Group 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 assessment, we rated this key question as good. At this assessment, the rating remains the same.

This service scored 69 (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 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. 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. Learning from incidents and complaints resulted in changes that improved care for others.

A previous learning event involved an information handling incident where confidential documents were accidentally printed to a centralised printer and left unattended. To prevent this happening again, a new process was introduced requiring staff to sign to confirm they have collected the correct documents. This helped ensure patient information was handled securely and reduced the risk of similar incidents in future.

The service worked with people and healthcare partners to establish and 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 when patients moved between services. Referrals and test results were managed in a timely way.

The practice had systems in place to identify and respond to safeguarding concerns. However, some improvements were required. The child safeguarding policy contained inaccurate information about required training levels, which was amended immediately during the assessment. In addition, care navigators were trained to Level 1 safeguarding, although the role requires Level 2. After the assessment, leaders told us that the training requirement had been updated to Level 2 on their system and that staff had now completed the required learning.

Despite these issues, regular safeguarding meetings provided structured oversight, concerns were addressed appropriately, and information was shared with relevant partners when necessary. Staff knew who the safeguarding lead was and felt able to seek support when needed. The practice also had a chaperone policy in place, and Disclosure and Barring Service (DBS) checks were undertaken where required.

The service 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. 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.

A care navigation system was used to help reception staff signpost patients to the correct clinician based on urgency and clinical need.

The service mainly detected and controlled potential risks in the care environment. However, there were some areas where risks had not been fully addressed. Emergency medicines and resuscitation equipment were stored in a treatment room, meaning they may not have been immediately accessible if the room was in use. In addition, at the Bevan site we observed uneven and cracked tarmac in the car park, creating potential trip hazards for people using the service. The practice informed us that repairs were currently on hold while the provider considered options for future development of the premises. After the assessment, leaders told us that emergency medicines and resuscitation equipment had been placed in reception areas at all sites to ensure immediate access, and that 2 quotes for car park repair and resurfacing work had been received with a 3rd awaited before a final decision was made.

Leaders also told us that fire risk assessments had recently been completed across all sites by an external health and safety consultancy, and that they were awaiting the final written reports. We saw email confirmation from the company confirming the reports were in progress.

While some areas required improvement, the provider held contact details for trusted maintenance providers, and health and safety risk assessments had been undertaken. Where risks had been identified, action had generally been taken to address them. A business continuity plan was in place, which was regularly reviewed and had been used effectively. This was demonstrated when the boiler failed at the Station Road site during the week of the assessment and staff promptly relocated services to other branch sites to ensure continuity of care.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. Staff worked together well to provide safe care that met people’s individual needs. There were a range of clinical and non‑clinical roles within the practice, and most mandatory training was up to date. Learning needs and staff development were managed appropriately, and staff were working within their agreed areas of competence. Safe recruitment practices were followed.

The practice had effective systems in place to ensure ongoing clinical competence. Joint monthly supervision sessions were undertaken for non‑medical prescribers (NMPs) and the physician associate, during which complex cases were discussed, staff were able to bring cases for reflection, and minutes were recorded. Appraisals for NMPs included documented case reviews, where a GP sampled prescribed items and checked these against the competency framework for prescribers to ensure safe and appropriate clinical decision‑making.

Staff undertaking extended clinical roles were appropriately trained, supervised and supported. The GP performing minor surgical procedures held Membership of the Royal College of Surgeons (MRCS) through the Royal College of Surgeons of Edinburgh and had completed a recent refresher course in minor surgery. The practice also carried out audits of minor surgical procedures to monitor outcomes.

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 practice had a designated infection, prevention and control lead and all staff had completed relevant training. Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks.

The service ensured that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes occurred.

As part of our assessment, we carried out clinical searches. Staff followed established processes to ensure people prescribed medicines with specific monitoring needs received the recommended observations. They took steps to prescribe medicines appropriately to optimise care outcomes.

A small number of documentation issues were identified. The medication reviews we saw had been completed, but in some cases, there was limited recorded evidence of the discussions that took place with patients, such as information about side effects, tolerance and ongoing suitability. For the patients we reviewed who were prescribed Pregabalin or Gabapentin (medicines commonly used for nerve pain), records did not clearly show structured review discussions or reduction plans where appropriate. Local prescribing data showed the practice’s use of these medicines was among the lowest in the area, with only a slight recent increase. We also identified 1 patient prescribed valproate who did not have the required annual risk acknowledgement form (ARAF) recorded on the system. This form is required as part of the valproate pregnancy prevention programme to ensure patients are fully informed of the associated risks.

The provider acknowledged these findings and confirmed that improvements would be made to strengthen the documentation of medication reviews. Leaders also told us that the required ARAF form had been requested, as the patient we identified had recently transferred into the area.

Staff managed medicines safely and regularly checked stock levels, expiry dates and storage temperatures for all medicines, including vaccines and emergency medicines. Medical gases were stored securely, and staff held appropriate authorisations under Patient Group Directions (PGDs). The provider had systems to manage and respond to safety alerts and medicines recalls, and staff followed established processes to ensure people prescribed medicines with specific risks received the recommended monitoring.

Our review of prescribing data showed that overall antibiotic prescribing at the practice was higher than the national expected level. However, prescribing remained below the average for the County Durham NHS System Integrated Care Board (SICBL), indicating comparatively lower antibiotic use within the local area.

The practice also used stronger antibiotics responsibly. Only 5% of antibiotics prescribed were broad‑spectrum (such as co‑amoxiclav, cephalosporins or quinolones), compared with a national expected rate of 8%, showing positive and safe prescribing in line with national guidance aimed at reducing antibiotic resistance.