Beaumont Park 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 requires improvement. At this assessment, the rating remains the same. We found a breach in the legal regulations in relation to safe care and treatment. The practice did not have effective systems to assess, monitor and continue to improve the quality and safety of the service

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Patient feedback regarding learning culture was limited. However, information we did receive was positive. One patient stated they felt listened to when they raised concerns and staff were friendly and professional. Patients were given the opportunity to provide feedback after each appointment, by a link which was sent out via text message for the Friends and Family test (FFT), to help assess people’s views or experience of the practice. However, we found there was no active patient participation group (PPG) and the practice did not display any patient feedback forms on the premises. Information on how to make a complaint was available at the reception desk and on the practice website.

Staff told us of an open and honest working environment, where they were supported by leadership, felt they were able to raise concerns and that their views were listened to and acted upon. Staff understood how to raise concerns and report incidents, however 54% of staff who responded to our staff feedback form said they were not made aware of complaints, or of improvements made because of a complaint, 45% of staff said that they were not invited to significant event meetings and 36% of staff said that the practice did not share incidents and learning with staff.

The practice had a significant events policy; however, the policy had never been reviewed therefore we could not gain assurance that the information was up to date or accurate. Significant events were discussed at the multidisciplinary team (MDT) meetings. We saw no evidence of complaints being discussed or of any learning which may have occurred from compaints being shared with the team.

We did not receive any patient feedback on this quality statement. The evidence we reviewed did not show any concerns about people’s experience regarding safe systems, pathways and transitions at this practice.

Staff told us about signposting and workflow systems regarding external services and the use of referrals. We found staff were knowledgeable in their role and were aware of support networks in the local area. Staff informed us there had been 52 referrals to social prescribing this financial year. Practice partners were positive about their interactions with the practice, describing how care was delivered and reviewed. They told us how care was coordinated when different teams, services or organisations were involved.

We did not receive any concerns from commissioners or other partners about safe systems, pathways and transitions.

There was a system and policy for processing information relating to new patients, including the summarising of new patients notes, but we could not gain assurance that the information was up to date or accurate. After the assessment the provider informed us that many of their policies were reviewed and updated in 2022, but this was not recorded within the policy and there was no date on the policy for the next review. The management of clinical test results were not managed in a timely manner. However, there were systems and processes to share information with staff and other agencies to enable them to deliver safe care and treatment. This included monthly multidisciplinary team (MDT) meetings between the practice and other health and social care professionals such as such as health visitors, social prescribers and district nurses.

We did not receive any patient feedback on this quality statement. Our observations raised no concerns. The evidence we reviewed did not show any concerns about people’s experience regarding safeguarding at this practice.

At the time of the assessment, the nominated clinical safeguarding lead had not completed the mandatory safeguarding training, whilst all other staff had. Leadership was made aware of this immediately, and training has since been completed. Partners told us that regular multidisciplinary team (MDT) meetings were held where safeguarding concerns would be discussed however, we were not assured that safeguarding concerns were a consistent standard agenda item because the records we reviewed did not support this. Leaders told us the practice did not have a clinical safeguarding deputy lead, and that the GP partners deputise for any absence, however this conflicts with the practices safeguarding policy for children and young people. The policy stated that a general practitioner (GP) was designated as the practice clinical safeguarding deputy lead, therefore we could not gain assurance that the information in this policy was up to date or accurate. Staff were able to tell us who the safeguarding lead was in the practice and how to raise concerns. They told us they received training in both safeguarding adults and children and had a clear understanding of their safeguarding responsibilities for reporting concerns.

We did not receive any concerns from commissioners or other system partners about safeguarding systems and processes.

Safeguarding policies were accessible to all staff. The policies outlined who to contact for further guidance if staff had concerns about a patient’s welfare, however we could not be assured the information in the safeguarding policy for children and young people was up to date or accurate. There were systems to identify vulnerable patients on records. Disclosure and Barring Service (DBS) checks were undertaken when required.

Data from the 2024 National GP patient survey showed that 94% of people that responded to the survey felt they had been involved as much as they wanted to be in decisions about their care and treatment.

Staff told us that they had opportunities to attend multidisciplinary team (MDT) meetings, but the practice did not have internal clinical meetings which they felt would be beneficial. Subsequent to the assessment leaders told us that there was allocated time for clinical discussions with staff, however, we could not be assured because the records reviewed did not support this. Ninety percent of staff who responded to our staff feedback form felt there were enough staff to provide safe, high-quality care. However, 54% of staff said they were not made aware of complaints, or of improvements made because of a complaint, 45% of staff said they were not invited to significant event meetings and 36% of staff said the practice did not share incidents and learning with staff.

We saw examples of minuted multidisciplinary team (MDT) meetings involving different health care professionals where patients were discussed to help manage risks associated with them. However, there were no routine in-house practice or clinical meetings to share identified risks and lessons learned with practice staff.

Staff told us that the building was too small and not fit for purpose, but they were in the planning process of getting a new practice built. Staff knew how to access the emergency equipment and emergency medicines.

We saw that emergency medicines were not stored appropriately. The emergency trolley was locked, and the key was stored in a different room, presenting the risk of a delay in access during a medical emergency. The trolley was stored in a location easily accessible to patients and was not secured, which presented a risk of medicines being removed from the premises by unauthorised persons. No risk assessments had been carried out to determine the range of medicines held or the location of the trolley. The practice did not do all that was reasonably practicable to mitigate risks to the health and safety of patients. The emergency fire exit did not have a ramp. The building’s large exit step made it inaccessible to those with mobility restrictions and no risk assessment had been carried out. The emergency call cord in the patient's bathroom was tied up, making it difficult to reach from the floor and 1 fire extinguisher was overdue its service. The practice had arrangements in place for managing waste and clinical specimens. Sharps bins were available in the clinical rooms: signed, dated and not over-filled.

There was a poilcy for Health and Safety, Fire safety and waste management, but we could not gain assurance that these policies were up to date or accurate. After the assessment the provider informed us that many of the policies were reviewed and updated in 2022, but this was not recorded within the policy and there was no date on the policy for the next review. We observed that there were no risk assessments in place; the practice hadn't performed a health and safety check since May 2023 or a legionella risk assessment since 2016. However, the practice had completed a fire evacuation drill, fire alarm service, emergency lighting checks, fire risk assessment, and provided evidence of annual portable appliance testing and calibration of equipment. Ninety-five percent of staff had completed their fire safety training.

The patient feedback we reviewed did not identify any concerns with staffing levels. Patients were complimentary about staff and the support they provided. Data from the 2024 National GP patient survey showed that 84% of people that responded to the survey had a good overall experience of the practice.

Leaders explained their recruitment processes and current staffing skill mix to ensure appropriate numbers of suitably trained staff were employed to support the delivery of care. Staff could request additional training if it was beneficial to their role. Staff told us they had received enough specific training for their role and had the support they needed to deliver safe care.

We reviewed the training records and found that not all staff were up to date with their mandatory training. There was a lack of oversight to ensure that mandatory training had been carried out and 19% of staff had not completed their basic life support training (BLS). There was no system in place for the practice to review the safety of clinical decisions made by clinical staff, working autonomously. The provider had a recruitment process in place. We reviewed 3 personnel files during the site visit and found appropriate recruitment checks had been carried out, including disclosing and barring (DBS) checks. There was a recruitment and DBS policy but we could not gain assurance that the information in the policies were up to date or accurate. After the assessment the provider informed us that the recruitment and DBS policy had been reviewed in 2022, but this was not recorded within the policies and there was no date on the policies for the next review. The provider had an induction programme for all newly appointed staff, but there was no locum GP induction programme in place. However, the latest available data from the National GP Patient Survey showed the practice was above national targets for childhood immunisations and cervical cancer screening, which indicated that there were enough qualified, skilled and experienced people to provide care that met people’s needs. Staff had yearly appraisals.

We did not receive any patient feedback on this quality statement.

Staff told us that they had completed their infection prevention and control (IPC) mandatory training, and they were aware of who the IPC lead was. Leaders explained that the IPC lead carried out regular IPC audits of the premises and equipment. In addition, we were told there were daily cleaning schedules of the clinic rooms.

We visited the practice and observed that, for the most part, the appropriate standards of cleanliness were being met. We saw that vaccine fridges were clean, frequently monitored and not over filled. Clinical bins were stored securely, personal protective equipment (PPE) was available, and information posters were displayed including those relating to effective hand washing and sharps injury management. However, we saw couch rolls were stored on the floor and one unclean cupboard that was not used for storage.

The practice had not completed a legionella risk assessment since 2016. There was an infection prevention control (IPC) policy but we could not gain assurance that the information in the policy was up to date or accurate. However, after the assessment the provider informed us that the infection prevention control (IPC) policy had been reviewed in 2023, but this was not recorded within the policy and there was no date on the policy for the next review. Systems were in place to ensure that the environment and clinic rooms were checked. The IPC lead nurse had completed an equipment audit in October 2024 and an infection prevention and control (IPC) audit in September 2024

We did not receive any patient feedback on this quality statement, however, our observations raised some concerns regarding medicines optimisation at the service.

Staff told us they followed protocols and National Institute for Health and Care Excellence (NICE) guidelines to ensure safe care and treatment was delivered. Staff had opportunities to attend multidisciplinary team (MDT) meetings, but the practice did not have internal clinical meetings which they felt would be beneficial. Leaders told us they had systems and processes in place to support the safe prescribing of medicines. The practice employed a clinical pharmacist who supported the GPs in the practice. The clinical pharmacist reviewed and actioned all medicine safety alerts. There were systems in place to monitor vaccines, emergency equipment and medicines. The practice did not have a process in place to monitor the doctor’s bag; leaders told us that the general practitioner’s had oversight, but this will now be added to the emergency check list, so it can be monitored on monthly basis by the advanced practitioner.

We saw that emergency medicines were not stored appropriately. The emergency trolley was locked, and the key was stored in a different room, presenting the risk of a delay in access during a medical emergency. The trolley was stored in a location easily accessible to patients and was not secured, which presented a risk of medicines being removed from the premises by unauthorised persons. No risk assessments had been carried out to determine the range of medicines held or the location of the trolley. However, we saw staff had the appropriate authorisations to administer medicines by Patient Group Directions (PGD) or Patient Specific Directions (PSD). Blank prescriptions were stored securely. There was medical oxygen and a defibrillator on site and systems to ensure these were checked regularly and fit for use. Vaccines were appropriately stored.

The practice had a system in place to monitor the storage of emergency medicines. Policies were in place for repeat prescribing and drug alerts, but we could not be assured the information in the policies were up to date or accurate. However, after the assessment the provider informed us the policies had been reviewed in 2022, but this was not recorded within the policy. We found there was a lack of processes established to ensure long term conditions and treatments were monitored regularly or robustly. Our search of the practice’s clinical system found that: Thirty-four patients living with asthma had received 2 or more courses of steroids in the last 12 months and were not offered a steroid card. The consultation records for people with asthma were of poor quality and there was little documentation to justify the issue of the steroids. There was no robust system in place for recognising patients who had overdue blood tests. SMS messages were sent but no further follow-ups were done. Our clinical searches identified 14 patients with hypothyroidism and 28% of patients on an Aldosterone antagonist medicine with heart failure were overdue their blood monitoring. We identified 71 patients with diabetes who’s latest HbA1c (blood glucose levels) was >75mmol/l. Of these patients, 19 were under hospital care. Many of these patients were overdue their medication review. We identified there was a significant lack of oversight of patient’s currently prescribed a direct oral anticoagulant (DOAC) medicine. Out of 191 patients currently prescribed a DOAC, 175 (91%) did not have the correct monitoring done in the last year. Leaders told us in response to this feedback immediate action was taken. There were 2-week-old abnormal blood results that had not been viewed or actioned. The practice failed to ensure an effective system was in place for acting on safety alerts. We identified 14 patients on both omeprazole and clopidogrel, which should not be prescribed together.

From the medicines optimisation (prescribing) data which is received by CQC from the NHS Business Services Authority (NHSBSA) we saw that the practice data was in line with national prescribing, except for 1 outcome which had higher prescribing: The average daily quantity per item for Nitrofurantoin, Pivmecillinam and Trimethoprim tablets prescribed for uncomplicated urinary tract infection from 01/04/2024 to 30/09/2024, was 6.21% compared to the expected average of 5.11%. Our monitoring showed that the practice was above national averages for routine childhood vaccination rates and for the number of patients screened for cervical cancer. We saw that monitoring of patients with some long-term conditions and certain types of medications needed to improve.