Dr B. Bekas

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

At the previous inspection in September 2023, we rated safe as inadequate because there were not effective systems in place to keep patients safe. Disclosure and Barring System (DBS) checks and recruitment checks were not carried out safely and in line with regulations. Blank medicines prescription forms were not kept securely or monitored in line with national guidance. Medicines were not always prescribed safely and patients receiving repeat medicines did not always receive the correct monitoring. There were no health and safety risk assessments or a fire risk assessment in place. At this inspection we found that these areas had not been adequately improved, and we found new areas of concern. Patients’ needs were not always assessed, and care and treatment was not always delivered in line with current legislation, standards and evidence-based guidance supported by clear pathways. There was limited oversight, induction and supervision for staff and learning from incidents and significant events had not been embedded to ensure people’s safety was integral to the care and treatment they received.

This service scored 31 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Information we reviewed demonstrated that people had opportunities to provide feedback, however we were not assured that the practice was actively reviewing and following this up consistently. Opportunities to provide feedback and information about the practice were available in the surgery and on the website. People told us they had enough time during their consultation, they felt involved in decisions about their care and treatment and had confidence and trust in the healthcare professional they saw or spoke to.

Staff and leaders told us of the systems in place to investigate concerns and share learning, however we found that this was not consistently followed. For example, staff told us that they were able to raise concerns, however they were unsure if their concerns would be investigated and managed appropriately. Staff understood their duty to raise concerns, report incidents and near misses. However, we found limited evidence that learning was shared to mitigate future risks. We also saw limited evidence that any actions or lessons learned were discussed with the staff team. We found that not all staff were involved in investigating significant events, complaints and identifying learning. Feedback from staff demonstrated that the practice had a poor culture of identifying all incidents and complaints and sharing learning to embed good practices. Some staff told us that their high workload meant that training and learning was not prioritised and at times completed outside of their working hours. We found that significant events and complaints were not consistently investigated and discussed. There were no records of actions taken in response to a complaint or incident and lessons learned were not routinely shared to drive improvement and patients’ experience of using the practice.

We found that the practice had systems and processes in place to investigate and report incidents, however these were not routinely followed. We found meetings were not held with staff to share learning. The practice had recorded 15 complaints for the period April 2023 to September 2024. We reviewed a sample of 6 written complaints and found no evidence of written responses. This was not compliant with the practice complaints policy. Staff understood their duty to raise concerns and report incidents and near misses. However, we found limited evidence that learning was shared to mitigate future risks. We also saw limited evidence that any actions or lessons learned were discussed with the staff team. Since the previous inspection, the practice had developed a system for oversight and monitoring of staff training, however, records we viewed demonstrated gaps in staff mandatory training. For example, safeguarding, chaperoning, equality and diversity, training to support autistic people and people with a learning disability, and infection control were pending completion for some staff.

The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety.

Staff had access to policies, resources and information to support best practice and the consistent delivery of high-quality care. However, all of the practice policies had been written or updated in the weeks prior to the inspection and staff were not familiar with them. We were told that training on all of the policies and procedures would be planned for the coming months.

Local partners told us that there was not consistent engagement from the practice.

There was limited evidence of 1 cycle clinical audits and no evidence of any 2 cycle audits. For example, the practice had carried out a 1 cycle audit to review 7 patients who had a HbA1c reading greater than 90/mmol/mol in December 2023. A HbA1c result at this level means you have too much sugar in your blood. This means you’re more likely to develop diabetes complications. This first audit included the need to carry out a 2nd cycle audit in June 2024, but this did not take place. This could mean that these patients were not receiving effective treatment for their conditions. Some information we received relating to audits was not current, for example an audit for the GP to update their knowledge on new drugs to treat diabetes was carried out in 2018. Staff were able to tell us the system in place for making two week wait referrals but was unable to describe the process for monitoring and following these up. We looked at some medicines alerts issued by the Medicines and Healthcare products Regulatory Agency (MHRA) and found that they had not all been actioned. For example, we found that for a group patients randomly selected who were prescribed carbimazole and pregabalin, there was no adequate discussion of the MHRA alerts dealing with the drug or any evidence of current contraception provision. Both of these medicines can potentially increase the risk of congenital malformations if used in pregnancy. We asked the practice to contact these patients to arrange a discussion. The GP confirmed that the patients were contacted for health monitoring.

Staff we spoke with were not able to share specific examples where safeguarding allegations had been discussed but told us they would report any concerns to the safeguarding lead. We were told that the safeguarding lead held meetings with other agencies to review any concerns and was supported by a non-clinical staff member who was tasked in updating safeguarding registers. The practice held a safeguarding register, but clinical system alerts were not routinely used to identify patients who were at risk of harm or abuse. We found that safeguarding registers required strengthening to include all patients who were at risk of harm or abuse.

We spoke with the safeguarding lead who told us they routinely met with the health visitor and midwife to review safeguarding concerns. However, safeguarding partners were unable to confirm that these meetings took place to support and protect adults and children at risk of significant harm.

Patient records were not always accurately coded where safeguarding concerns had been identified. Clinical system alerts were not always used to identify patients who were at risk of harm or abuse and the system in place was not managed effectively. This had been identified during our previous inspection in September 2023. We were told there were processes in place to follow up children and young people who were not brought to their appointments both at the practice and for secondary care appointments, however we were not presented with any records to confirm this practice took place. We were not assured of this process during our assessment. There was no named freedom to speak up guardian in place, which is important as some staff can feel particularly isolated because they work in smaller practices, or they fear a risk to their employment if they are raising concerns about someone who may be their direct employer.

Results from the national GP survey results 2024 demonstrated that 93% of patients had confidence and trust in the healthcare professional they saw or spoke to during their last general practice appointment which was just below the national average of 92%.

We found some evidence that leaders worked with other agencies to understand and manage risk, but this was not always consistent. The practice had registers in place to support those patients who were vulnerable or who had mobility or communication needs, however we found a lack of processes and oversight in ensuring these were routinely monitored. The GP who is the safeguarding lead, had a paper folder with some safeguarding information in it relating to patients. These patients were not on the safeguarding register on the system, meaning that risks may not be identified addressed by other members of the practice team. We found gaps in staff training and staff had not completed sepsis awareness training. However, staff were aware of actions to take if they encountered deteriorating or acutely unwell patients, but there was no assurance that they would be able to identify the signs and symptoms of sepsis.

We found that processes required strengthening to ensure risks were managed appropriately. We found some clinical risks in relation to patients prescribed high risk medicines, those that had long term conditions and those with a potential misdiagnosis. We found concerns during our assessment that some patients had not been monitored appropriately or followed up to ensure they were receiving the correct care and treatment. There were some processes in place to ensure the practice prioritised care for their most clinically vulnerable patients, however we were not assured that patients were told when they needed to seek further help and what to do if their condition deteriorated. There were some systems in place to support patients who face communication barriers to access treatment (including those who might be digitally excluded).

Since the previous inspection, staff told us that work had begun to improve the safety of the physical environment. However, a fire risk assessment, health and safety risk assessment and fire drills had not taken place. There was not a working fire alarm in place. We found some staff were out of date with training updates, which included fire safety training. An infection, prevention and control, (IPC), audit had been completed by the local Integrated Care Board, (ICB), but there was no evidence that actions required from this audit had been addressed.

During our site visit we found concerns that areas within health and safety and fire safety had lapsed and had not been appropriately actioned. We saw that the IPC monitoring procedure for one of the clinical rooms had not been followed. We found a lack of overall leadership in place to manage this safely.

We found concerns in the lack of processes in place to manage the safe environment of the practice. There were policies and procedures in place for the management of health and safety, however some areas had not been maintained and action was required to address the shortfalls.

The results from the GP National Patient Survey 2024 demonstrated that 68% of patients who completed the survey were satisfied with the overall experience of making an appointment compared to a national average of 74%.

There were policies and procedures in place for the safe recruitment of staff. We did not find that there were always clearly defined lead roles to support staff. For example, we found that there were unclear lines of responsibility between the practice manager and the lead GP. Some mandatory learning for staff was overdue and was not being appropriately followed-up. Since the previous inspection, a process to enable staff to increase their skills had been put in place. However, this was a new programme and staff told us that they did not have time to learn new skills and complete their training at the same time as maintaining their current workload.

We did not gain assurances that the practice had clear processes in place to manage safe and effective staffing. We examined a sample of staff files and saw evidence that disclosure and barring system (DBS) checks and other standard recruitment checks for some staff working in the practice had not been undertaken. Since the previous inspection a procedure had been put in place for staff to receive an annual appraisal and we found that in the sample of staff files we examined, these had taken place. Since the previous inspection an induction programme had been devised, but we saw no evidence that new staff had completed this. The practice could not demonstrate how they assured the competence of staff employed by the local Primary Care Network, (PCN), in advanced clinical practice, including nurse practitioners, paramedics and pharmacists. There was a lack of oversight, audits and clinical supervision arrangements in place.

We did not gain feedback around infection prevention and control with patients during this assessment. However, the shortfalls we identified in relation to the premises and environment could impact people’s experience.

The practice had an infection control lead in place who was familiar with the recent audit that the ICB had undertaken. However, there was no evidence of an action plan to rectify the issues that arose from that audit. There were policies and procedures in place, but not all staff were aware of who the IPC lead was in the practice.

We observed the clinical rooms to be generally tidy. Sharps bins were available in all clinical rooms which were signed, dated, safely sited and were not over-filled. However, on the day of the site visit we saw an example where the IPC procedure of checking each clinical room at the end of a session had not been followed.

The practice had policies in place for infection, prevention and control. There was an infection control lead in place and an infection control audit had been carried out by the Integrated Care Board in February 2024 and the practice had achieved a score of 83% compliance. However, we found that not all of the actions required from this audit had been completed. IPC training was overdue for some staff working in the practice.

During the inspection we identified some concerns in the management of high-risk medicines, safety alerts and medicine reviews which meant that patients had not always been identified or followed up in a timely way. We found that there was no robust system in place to ensure the practice had taken action to review safety alerts to ensure that these were being followed appropriately to ensure people were protected from harm. There was no clear process in place for recalling patients to ensure they had access to appropriate monitoring and information to manage their health needs.

The practice told us they worked with the clinical pharmacists from the local Primary Care Network to identify prescribing and management of patients receiving high risk medicines and medicines which require monitoring. However, we were not assured that there was clear oversight.

We found that vaccines were appropriately stored. However, we saw evidence of an incident where a vaccine fridge had malfunctioned, and the vaccines had been disposed of without keeping a record of the identifying batch numbers. We found that patient group directions or PGDs (a written instruction for the administration of medicines to groups of patients not previously prescribed for) were in place.

Clinical care records did not always demonstrate oversight and structured medicines management reviews. Where a review had been carried out for patients, we found individual care records contained minimal or no commentary and were not adequately documented. During the clinical reviews we found that not all medicine alerts had been acted on and high-risk medicine and monitoring for patients with long-term conditions were overdue for some patients.

We looked at the prescribing of a medicine, methotrexate. This medicine is a disease-modifying antirheumatic drug, (DMARD) used to treat inflammatory conditions such as rheumatoid arthritis. It requires regular blood monitoring due to the risk of side effects. We found that 2 patients were prescribed the medicine, and both were overdue monitoring. The monitoring of patients who were prescribed DMARD medicine was shared with the local NHS trust, and we saw that this process required strengthening as patient records did not always contain the most up to date information from the local trust. We saw that 5 patients were prescribed an aldosterone antagonist, which is a medicine used to treat high blood pressure and heart failure. We saw that 2 of these patients had not received the required monitoring. This medicine can worsen renal function and induce hyperkalaemia, and patients should be reviewed regularly. Metformin is a medicine to help control blood sugar levels. Our searches found 2 patients with a low renal function were prescribed this medicine which is not in line with British National Formulary (BNF) and MHRA guidance. Records of actions taken against medicine alerts were not evidenced. We carried out a search to look at an MHRA alert relating to people who were prescribed a teratogenic medicine. This group of medicines can cause birth defects or other abnormalities in a foetus during pregnancy and guidance states that a discussion with the patient must be documented before one of these medicines is prescribed. We identified 10 patients who were prescribed one of these medicines and reviewed 6 of them. We found that 5 of these 6 patients had no discussions documented around the risk in pregnancy, which meant they were possibly unaware of the risks if they became pregnant.