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 has changed to good.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. Managers encouraged staff to raise concerns when things went wrong. During staff meetings, the whole team discussed and learnt from clinical issues. Staff felt there was an open culture, and that safety was a top priority. The provider had processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Learning from incidents and complaints resulted in changes that improved care for others.

A recent learning event involved a routine clinical procedure being carried out earlier than intended due to the timing of a patient’s appointment. The practice discussed the incident at the clinical monthly meeting and reinforced the correct process for documenting the date of administration and the next planned date, ensuring the information was recorded clearly and consistently to prevent future errors. This learning was shared with the clinical team; however, the practice recognised that sharing it with the wider team, including administrative staff, would further support safe scheduling and strengthen overall learning.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Systems were in place for processing information relating to new patients, managing test results, and coordinating referrals. The service collaborated with other providers to deliver shared care and manage transitions.

Referrals to specialists and urgent services, including 2-week-wait (2WW) referrals, were managed through a clear process. Once a 2WW referral template was completed, the secretarial team monitored it using a tracking spreadsheet to ensure no referrals were missed.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations.

Most staff had completed safeguarding training appropriate to their role. However, 1 member of staff did not have the correct level of safeguarding training; this was promptly addressed by the provider, and the training requirement was updated immediately.

The practice had a chaperone policy in place to provide reassurance and mitigate risk for both patients and staff. Disclosure and Barring Service (DBS) checks were undertaken when required.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Emergency equipment was available and maintained. Staff could recognise a deteriorating patient and knew of action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

The service mainly detected and controlled potential risks in the care environment. However, there were some areas where risks had not been fully addressed. The practice completed a Health and Safety Inspection Checklist in May 2025, which identified 2 risks: doors on escape routes not opening easily, and the absence of Display Screen Equipment (DSE) assessments for all screen users.

In the July 2025 Fire Risk Assessment, the assessor identified that several fire‑resisting doors were not in sound condition and recommended a visit from a third‑party fire door engineer within 2 months. This had not been arranged at the time of the assessment.

The provider told us they would complete the outstanding DSE assessments and arrange for a third‑party fire door engineer to visit.

Despite these issues, the service ensured that equipment, facilities and technology generally supported the delivery of safe care. Contracts were in place to ensure the premises were maintained. Health and safety risk assessments and audits had been undertaken, and most identified risks had been acted upon. A business continuity plan was also in place and monitored and reviewed.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. However, clinical competency was not formally monitored, and there were no documented case reviews to evidence ongoing assessment of clinical practice. Clinical staff did have access to prescribing update courses, took part in annual appraisals, and engaged in ad hoc informal case discussions. There was also a dedicated session each afternoon for clinical staff to meet with the GPs for additional support.

Staff worked well together to provide safe care that met people’s individual needs. There were a range of clinical and non‑clinical roles within the practice. Training was up to date, staff development and learning needs were managed appropriately, and staff were working within their agreed areas of competence. Safe recruitment practices were followed.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The practice had a designated infection, prevention and control lead and all staff had had relevant training. Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks.

The service ensured that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes occurred.

As part of our assessment, we carried out clinical searches. The practice had made improvements since the last assessment, particularly in medicines optimisation and the monitoring of high‑risk medicines. The review showed clear progress in the safe prescribing and monitoring of patients prescribed Direct Oral Anticoagulants (DOACs).

Staff followed established processes to ensure people prescribed medicines with specific monitoring needs received the recommended observations. They took steps to prescribe medicines appropriately to optimise care outcomes. A small number of issues were found. In some cases, medication reviews had been completed but lacked clinical detail. We also identified a group of 89 patients (1.4%) who had been prescribed non‑steroidal anti‑inflammatory medicines (NSAIDs) or antiplatelet medicines without also being prescribed a medicine to help protect the stomach. Without this, there was an increased risk of stomach irritation or bleeding. The provider acknowledged this finding and confirmed that the cohort of 89 patients would be reviewed. They also advised that this would be discussed at the next Multidisciplinary Team meeting (MDT meeting).

Staff managed medicines safely and regularly checked stock levels, expiry dates and storage temperatures for all medicines, including vaccines and emergency medicines. Medical gases were stored securely, and staff held appropriate authorisations under Patient Group Directions (PGDs).

The provider had systems to manage and respond to safety alerts and medicine recalls. However, we identified a small number of patients (3) over the age of 65 who had been prescribed citalopram, which is included in a safety alert from the Medicines and Healthcare products Regulatory Agency (MHRA) for this age group and requires a dose review. Leaders told us that immediate action was taken to contact the affected patients.

Our review of prescribing data showed that the practice’s use of antibiotics was in line with local and national averages. Prescribing antibiotics appropriately helps reduce the risk of antimicrobial resistance, which can make infections harder to treat.