Beaumont Park Surgery

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment, we rated this key question as good for providing a well-led service, now we have rated the practice as requires improvement. We found a breach in the legal regulations in relation to good governance. The practice did not have embedded governance systems, there was lack of oversight and there was no evidence of systems and processes for continuous improvement and innovation. There was no learning from complaints or significant events. However, a new practice manager had recently been appointed and the practice spoke positively about moving forward and there was a focus on improvements across the organisation to deliver safe and effective care.

This service scored 39 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The leaders at the practice spoke positively about moving forward, their direction and culture and about making improvements to the service. Staff reported there was an open and honest culture within the practice, and they felt able to raise concerns without fear of retribution. Staff who responded to the staff feedback questionnaire said that the practice had a clear vision for the future, and they knew what whistleblowing was, however 28% of staff said they were not sure if the practice had a freedom to speak up guardian and how to contact them.

We asked for a copy of the practice future business plan; however, we were informed this had yet to be developed. The practice was unable to locate the Equality and Diversity policy and told us they would develop a practice policy.

Leaders told us they had an open-door policy, and that staff received yearly appraisals. All staff who responded to the staff feedback questionnaire said leadership were approachable and that they felt supported by managers. The majority of staff reported a positive working environment, however, 18% of staff said at times it could be stressful due to their workload.

There was a business continuity plan in place which was last reviewed July 2024. Records showed staff had received an annual appraisal or had a date scheduled. There were policies for complaints, however we saw no evidence of complaints being discussed or that lessons learned were being shared with the team.

Staff reported there was an open and honest culture within the practice, and they felt able to raise concerns without fear of retribution. Staff who responded to the staff feedback questionnaire said that they knew what whistleblowing was, however 28% of staff said they were not sure if the practice had a freedom to speak up guardian and how to contact them.

Seventy five percent of staff had completed the freedom to speak up training and the practice had a freedom to speak up guardian for staff to speak to who worked at a neighbouring practice. There was a whistleblowing policy in place, however, the policy had never been reviewed therefore we could not gain assurance that the information was up to date or accurate.

All staff who responded to the staff feedback questionnaire said they had completed the equality and diversity training and that they felt supported by managers. Staff gave examples of changes made as a result of staff feedback. Leaders told us they had an open-door policy, and they had daily check ins with staff to ensure their well-being.

We found limited processes in place to review and improve the culture of the practice in relation to equality, diversity and inclusion. The practice was unable to locate the Equality and Diversity policy and told us they would develop a practice policy. Ninety percent of staff had completed the Equality and Diversity training.

Leaders told us they were aware the practice’s polices had not been dated and all policies needed reviewing. 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.

We found policies, systems and processes required improvement to ensure the quality and safety of care provided. Risk assessments had not been completed for health and safety at the time of the assessment and the management team were unable to provide us with any evidence of what risk assessments were in place. We saw no evidence of significant event analysis, or of any learning which may have occurred being discussed and shared with staff in team meetings to mitigate future risks and identify trends. We found quality improvement activity did not always take place. There was a lack of clinical audits to improve outcomes for patients The practice had several policies in place, but these had not been reviewed or dated, and some policies contained inaccurate information. The practice did not ensure systems were operating effectively in respect of medicines management. On reviewing a random sample of patients on high-risk medicines or with long term conditions we found they had not received the appropriate reviews, and we found 2-week-old unactioned pathology results. There was lack of oversight to ensure that mandatory training was kept up to date.

We did not receive any patient feedback on this quality statement. There was no active patient participation group (PPG). There was a link with information on how to join the PPG on the practice website, but we were not provided with any evidence to demonstrate what had been done within the practice to encourage patients to join.

Staff we spoke to explained the processes in place for making referrals to other services and the partnerships they had in place, such as social prescribing. However, they did not give us any examples of how the practice reached out to the local community or sought their feedback, other than through the National GP Patient Survey or the Friends and Family Survey.

We did not receive any concerns from commissioners or other system partners about partnerships and communities.

We found some evidence to demonstrate that the practice had processes in place for partnership and community engagement. For example, we received evidence to demonstrate that multi-disciplinary team (MDT) meetings were being held. Leaders told us that patients with a palliative diagnosis would be discussed in the monthly MDT meetings. Since our assessment the practice told us they held an MDT meeting with MacMillan Nurses, District Nurses and a Palliative Care Consultant and re-introduced an identification system which can be used to quickly prioritise those patients with the most pressing clinical needs.

Staff told us that complaints and significant events were not shared. On reviewing the minutes of the meetings, we found no evidence to demonstrate that incidents or complaints had been discussed to ensure that improvements were made, and that learning was shared with the practice team to mitigate risks.

The practice leaders were unable to demonstrate they had effective systems in place for learning and development. We identified gaps in staff training records. Leaders were unable to locate a staff training policy and told us they would develop a practice policy. 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. We found quality improvement activity did not always take place. There was lack of clinical audits to improve outcomes for patients. As part of our clinical searches, we identified instances in which the clinical monitoring of patients was inadequate. There were not processes in place to ensure quality of care was reviewed, and national safety alerts were acted upon. For example, we identified 14 patients on both omeprazole and clopidogrel, which should not be prescribed together.