Bellbrooke 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

Complaints and incidents were discussed and used to make improvements. Audits and risk assessments were also carried out regularly and used to drive improvement. The premises were clean and tidy, and staff understood the importance of keeping people safe and how to escalate any concerns. However, we found issues with the processes in place regarding fire evacuation. Our review of clinical records identified that safety alerts were not always actioned in line with guidance and patients did not always receive appropriate monitoring. In addition, clinical staff received support and supervision however there was no formal process in place for this. There were no dedicated multidisciplinary adult safeguarding meetings or process for reconciling information with local authority teams. However, following our assessment, the provider shared evidence of best interests meetings held with the local authority to discuss specific patients.

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.

As part of the assessment process, we asked the practice to invite patients to share their experience of the service. There was no feedback to indicate concern in this area.

Leaders told us about their learning processes and the ways in which they used learning to improve services. This included learning from significant events, complaints, audit findings, and feedback. An example of this is an incident where a patient had not been advised to temporarily stop taking their medication after becoming unwell. This incident was discussed in a clinical meeting and a ‘sick day rules’ protocol was subsequently produced to advise patients of when to stop taking their medication if unwell. Leaders also told us that they encouraged staff to report incidents and had a no blame culture. We were told that information from these meetings was shared with staff by email, however feedback from some staff indicated that this method of sharing information with them was not always efficient.

There were policies and processes in place to record, investigate and take action from incidents and complaints. These were discussed in clinical meetings and minutes were circulated to staff via email. However, we saw that a small number of complaints had not been responded to in a timely manner include signposting to the Parliamentary and Health Service Ombudsman. For example, records showed that 7 complaints had been received. We reviewed 3 of those in detail and saw that 1 had not been responded to in a timely way. Following the assessment the provider submitted a summary which showed that the majority of complaints were responded to on a timely basis. There was a process in place for recording and sharing medicine safety alerts, however a review of clinical records indicated that safety alerts were not always actioned in line with guidance. For example, we looked at patients aged 65 and over who were prescribed over the recommended maximum dosage of citalopram (20mg). We reviewed 5 of the 7 patients identified by this search and saw that only 1 patient had a documented record of risks associated with the dose and confirmation that they were happy to continue. Clinical and non-clinical audits were carried out, and these resulted in improvements to processes and patient care.

As part of the assessment process, we asked the practice to invite patients to share their experience of the service. There was no feedback to indicate concern in this area.

Leaders told us that they worked with others to establish and maintain safe systems of care for patients. We saw that the number of new cancer cases treated resulting from an urgent cancer referral, using latest data from March 2022, was in line with the national average. Staff we spoke with understood the referrals processes and how to safely manage correspondence.

As part of the assessment process, we asked the NHS West Yorkshire Integrated Care Board to share their experience of the service. There was no feedback to indicate concern in this area.

Protocols were in place to support workflow and pathways for appointments, referrals, records summarising and correspondence. There was a protocol in place to ensure that designated clinical staff were available each day to process laboratory results. There were processes to monitor and manage care when patients were moved between services such as after referral to secondary care, or admission to hospital. There was however a backlog of patient records to be summarised. Actions taken to address this included recruitment of a new staff member and use of new patient questionnaires to mitigate risk.

As part of the assessment process, we asked the practice to invite patients to share their experience of the service. There was no feedback to indicate concern in this area.

Staff told us how they used the clinical system to record and alert others to safeguarding concerns, and how they escalated safeguarding concerns within the practice. Staff explained their responsibilities around reporting and recording incidences of female genital mutilation.

As part of the assessment process, we asked the NHS West Yorkshire Integrated Care Board to share their experience of the service. There was no feedback to indicate concern in this area.

There were designated safeguarding children and adult leads at the practice and a safeguarding policy containing relevant contact details. At the time of the assessment most staff were up to date with training in these areas. Some staff who carried out chaperoning had not received any refresher training for some time and when speaking to some staff members, it was evident that there were some gaps in their understanding of the chaperone role. After the assessment we saw that the practice had arranged further chaperone training for staff. Children safeguarding cases were discussed in monthly multidisciplinary meetings. However, there were no dedicated multidisciplinary adult safeguarding meetings or process for reconciling information with local authority teams. We saw evidence of adult safeguarding discussions being carried out in clinical and case discussion meetings and following our assessment the provider submitted evidence of best interests meetings held with the local authority to discuss specific patients.

As part of the assessment process, we asked the practice to invite patients to share their experience of the service. There was no feedback to indicate concern in this area.

Staff we spoke with knew where to locate emergency drugs and equipment and were able to explain how to act safely in an emergency, including alerting clinical staff and emergency services.

The practice had emergency medicines and equipment on site. From records we reviewed, and checks we made on the day, we saw that these were sufficient for the needs of the practice and were monitored and maintained as required.

Leaders told us that they had developed and adopted health and safety management processes to ensure the safety and wellbeing of patients, staff and visitors to the practice. The practice informed us that staff had undertaken required mandatory training in respect of health and safety and had appointed staff to key roles such as fire marshals. Staff we spoke with on the day of our inspection visit told us that they had no concerns related to health and safety in the practice.

We saw that the premises was in a good structural condition, and that equipment was maintained regularly, stored safely and was suitable for use. For example, fire extinguishers had recently been serviced, and clinical equipment had been calibrated to ensure correct operation.

The provider had established some management processes which gave assurance that health, safety and wellbeing requirements were met. For example, the practice had commissioned a legionella risk assessment which had been carried out in January 2024. We saw that issues raised in this risk assessment had either been actioned or were in the process of being actioned. The practice had completed a health and safety risk assessment which covered key areas such as lone working and trips, slips and falls. There was fire evacuation chair to facilitate patients with mobility issues to safely exit the premises in the event of a fire. However, it was not clear if staff had received the necessary training to ensure the safe and effective operation of the chair. It was noted that a fire drill had not been undertaken by the practice for over 2 years. There was a fire safety policy but this did not specify the required number of fire evacuation drills to be undertaken per year. The practice confirmed that a fire drill had been carried out the day after the assessment and updated the policy to state that these would be carried out at least every 12 months.

As part of the assessment process, we asked the practice to invite patients to share their experience of the service. There was no feedback to indicate concern in this area.

Leaders told us about the ways in which they ensured staff were qualified and skilled to carry out their roles, and the support that they offered them. This included carrying out security checks during recruitment and providing staff with mandatory and role-specific training. Staff told us they had enough support to carry out their role and could seek further guidance from senior staff when needed. Leaders told us they monitored staffing levels and did not use locums often as staffing levels were usually sufficient.

Policies on recruitment, induction and staff appraisals were in place. Staff also had access to an induction pack which provided key information such as training and development goals. A locum induction pack was available to locums to provide them with the necessary information to carry out their role safely. Trainees and non-medical prescribers had dedicated mentors and adequate clinical support. However, we saw no formal processes to monitor clinical competencies and support sessions were not formally documented. We reviewed some staff personnel files as part of this assessment and found that documentation was generally in line with guidance. This included Disclosure and Barring Service (DBS) checks, training and immunisation records. Some staff did not receive yearly appraisals, and the practice appraisal policy did not clearly specify how often appraisals would be carried out. The practice told us they aimed to carry out yearly appraisals for clinical staff although there was evidence that not all staff were up to date with this. There was no formal appraisal period for non-clinical staff as the practice told us they had deemed them to be unpopular, however they said that staff could request an appraisal at any time, and we saw that some had been carried out. Staff that we spoke with and received feedback from as part of this assessment told us they felt supported.

As part of the assessment process, we asked the practice to invite patients to share their experience of the service. There was no feedback to indicate concern in this area.

Interviews and feedback from staff showed us that they had a good understanding of infection prevention and control (IPC). Staff were aware of how to raise concerns regarding IPC, and who to contact when they identified issues. The IPC lead who had been appointed by the practice had a good understanding of their role, and told us that they had received additional training, support and protected time to effectively deliver IPC related activities. They told us when they identified any issues in respect of IPC, that these were listened to and actioned by the practice management team.

We found the practice premises and equipment to be clean and hygienic, which protected people from the risk of infection. Cleaning within the practice was undertaken by an external company. We saw that cleaning schedules and records were in place and the cleaner’s cupboard was well stocked with cleaning equipment and cleaning products. We saw that personal protective equipment was readily available in consultation rooms for staff use.

The practice had an IPC policy in place which had been reviewed in April 2024. We saw that it contained appropriate information to support effective maintenance of standards. We saw that both internal and external audits of IPC had been undertaken at the practice. For example, an externally accredited audit had been undertaken in August 2024 which showed that the practice had achieved a compliance score of 91.6%. Following audits, we also saw that action plans had been developed, and measures taken to tackle areas of non-compliance. IPC training was undertaken on induction, and as part of a regular mandatory training programme. The practice had a clinical waste contract in place which ensured such waste was removed on a weekly basis.

As part of the assessment process, we asked the practice to invite patients to share their experience of the service. There was no feedback to indicate concern in this area.

Leaders told us that performance in relation to medicines outcomes was closely monitored through discussions in clinical meetings and through clinical audits. For example, in response to recognising a high-risk population for gestational diabetes, the practice carried out an audit involving checking of codes and up to date blood testing for these patients. Actions included reminding staff about the importance of correct coding and checks as well as educating patients. The latest re-audit showed an increasing number of patients being coded with gestational diabetes and a higher percentage of patients being up to date with their blood tests. In order to ensure continued safe prescribing for patients who had not attended for required medicines monitoring, these patients were subject to repeated contacts to encourage attendance and when necessary, prescribed lower amounts of medicines. Staff told us they received appropriate training and supervision in medicines management, including the management of vaccines.

As part of our assessment a CQC GP specialist advisor (SpA) undertook searches of patient records on the practice’s clinical system. Findings included: Methotrexate (a disease-modifying anti-rheumatic drug): 9 out of 29 patients were identified as not having required monitoring in last 6 months. We reviewed 5 patients and found that 1 patient was under the care of the hospital and 1 patient had not requested a prescription for 3 months. We saw that the remaining 3 patients had been invited to attend appointments following the announcement of our assessment. We found that prompts on the clinical system were not always considered, for example lithium monitoring every 3 months was present on some patient records and this had not been actioned. Lithium (a mood stabiliser): 4 out of 7 patients identified as not having required monitoring every 3 months. We saw that 2 patients had been booked to attend appointments shortly after our clinical searches, 1 patient had bloods done recently but no lithium level monitoring and 1 patient had not responded to recalls so no medication was prescribed. Medication reviews: There had been 1011 medicines reviews in the last 3 months. Of the 5 we reviewed, 4 did not contain evidence of detailed discussions about the patient’s medicines. Medicines usage: 123 patients had been appropriately prescribed a combined oral contraceptive pill in the last 12 months, as none had a history of venous thromboembolism. After the assessment the practice told us they would be reviewing these findings in their next clinical meeting and would make any required changes.

Medicines within the practice were effectively ordered, stocked and monitored. There were Patient Group Directions and Patient Specific Directions in place which relevant staff worked to. There was a process in place to ensure prescription stationery was logged and stored securely. Refrigerators used to store vaccines and medicines were regularly cleaned, temperatures were monitored and logged, and products were appropriately stored within them. The practice participated in the Lowering Antimicrobial Prescribing (LAMP) audit and Campaign to Help Improve Respiratory Prescribing (CHIRP), and as a result had a good overview of their overall prescribing performance.

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 as the practice performance was in line with national averages for all indicators. For example, data for March 2024 showed that the percentage of Co-amoxiclav, Cephalosporins and Quinolones prescribed was at 6.0%, compared to the national average of 7.8%.