Lighthouse Group 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 assessed and inspected against one quality statement; Safe and effective staffing. During our assessment of this key question, we identified that although staff were supported to carry out their roles and responsibilities, clinical supervisions were not always formally recorded in line with practice policy. Staff training that was deemed mandatory by the practice had not always been completed and systems were not always effective to monitor compliance to training completion. We found arrangements to plan administrative and clinical staff resources including rotas were managed effectively to meet service user's needs.

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.

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

People could feed back their experience of the service via Working Feedback, which incorporated Friends and Family Test (FFT) information. We reviewed patient feedback from August 2024 and found 2027 feedback invitations had been sent with 51 completed submissions. We identified examples of positive feedback relating to staff such as clinicians listened to people and provided good quality care and treatment. Both clinical and administrative staff were described as professional and friendly.

There were sufficient staff to ensure people’s records were kept up to date. Leaders told us two administrative staff from the workflow team managed summarising and clinical coding. Staff had the most up to date clinical information to support their knowledge, inform treatment decisions and care planning. Staff told us that there were opportunities to ask for support, raise concerns and appraisals were carried out annually. Staff could discuss clinical queries in relation to their medicine prescribing or care and treatment planning with leaders who they said had an ‘open door’ policy. The duty GP held weekly clinical supervision sessions to discuss performance, care and treatment. Leaders told us that staff rotas were planned 4-12 weeks ahead of time. Administrative staff were deployed effectively to manage patient demand from urgent online requests. The practice had implemented additional clinical staff, scheduled once per week, to assist with urgent care requests to prevent long appointment waiting times. A new Human Resource (HR) manager had been recruited and due to start in October 2024. This would assist with oversight of maintaining staff records to ensure these met the standards of the practice recruitment policy and Schedule 3 requirements of the Health & Social Care Act 2008. A mixture of staff members had chaperone responsibilities as part of their role. Those staff members had completed relevant training and were able to describe procedures to ensure patients were kept safe. The practice’s clinical system recorded observations and notes by the chaperone for each required consultation. Leaders demonstrated that there were adequate clinical staffing arrangements to ensure in the event of emergency, the risk of unsafe practice was mitigated and there was no lone working. The practice had a business continuity plan in place which gave guidance to staff for the preparation of major incidents. Staff were able to demonstrate how to access practice policies.

The practice had identified in May 2024 they had not checked all practice and Primary Care Network (PCN) staff’s Disclosure and Barring Service (DBS) status upon recruitment. The DBS carry out a criminal record and barring check on individuals who intend to work with vulnerable adults and children, to help employers make safer recruitment decisions. In response, the practice had retrospectively sought DBS checks for those staff members and conducted individual risk assessments and bespoke working arrangements whilst awaiting the outcome of DBS checks. The practice had worked with the local commissioners and kept CQC informed during this time of the remedial actions they were taking to ensure patients were kept safe. We found the practice had taken learning from this and were completing DBS checks as part of their pre-employment procedures of newly recruited staff. All recruitment and Human Resource (HR) records were not always kept in-line with practice policy and Schedule 3 requirements of the Health and Social Care Act 2008. We carried out a review of the provider’s recruitment checks in relation to 7 members of staff and information was not always available and up to date in line with practice policy. This included a lack of information relating to staff’s health and immunisations. This was required to ensure they were safe to carry out their roles and ensure people were kept safe from the risk of infection by reducing their exposure to infectious diseases. HR records did not always contain staff agreements to the practice confidentiality policy. This meant there was a risk that not all staff were aware of information governance processes and data requirements. Although clinical supervisions took place for some staff; records did not show all staff’s performance and competencies were routinely and consistently assessed. A record would ensure staff’s identified learning and development needs and how they were supported to meet these.

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

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