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 requires improvement. At this assessment, the rating has changed to good.

This service scored 71 (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 shared vision, strategy and culture based on transparency, equity, equality and human rights. It promoted diversity and inclusion, engagement, and an understanding of the challenges and needs of people and their communities.

Staff told us there was an open and honest culture within the practice. They felt confident to raise concerns without fear of retribution and believed that their views were listened to and valued. Staff also said that there was a clear vision for the future.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Staff told us that leaders were approachable and responded to any concerns raised. Staff described a leadership team that supported their wellbeing and professional development and promoted an open and learning‑focused culture where learning was encouraged when relevant to their role.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

The practice had established Freedom to Speak Up arrangements, and staff told us they knew how to raise concerns if needed. Most staff who responded to the feedback questionnaire confirmed that they understood what whistleblowing was and how to report concerns.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Policies and procedures were in place to support equality and diversity, and leaders took steps to ensure staff felt supported and able to perform their roles effectively. Staff told us the organisation was responsive to individual needs and made reasonable adjustments where required. These included adapting workspaces, providing ergonomic or accessible equipment, and ensuring staff with health conditions or disabilities had suitable tools to carry out their duties safely.

The service had governance arrangements in place, although some areas required strengthening to provide full assurance around safety and oversight. For example, there was no formal documented process to support clinical competency for non-medical prescribers.

Required actions identified in key safety assessments had also not been followed up. In the July 2025 Fire Risk Assessment, the assessor reported that several fire‑resisting doors were not in sound condition and recommended a third‑party fire‑door engineer review within 2 months. This had not been arranged at the time of assessment. Similarly, the Health and Safety Checklist completed in May 2025 identified 2 risks, escape‑route doors not opening easily and outstanding DSE assessments for screen users. No follow‑up action had been recorded, and DSE assessments had not yet been completed. The provider told us they would complete the outstanding DSE assessments and arrange for a third‑party fire door engineer to visit.

While some areas required improvement, the practice had made progress since the previous assessment in strengthening its governance arrangements, introducing regular team meetings, ensuring greater oversight of policies and clinical activity. The practice had clear roles, responsibilities, and systems of accountability that supported the delivery of good quality and sustainable care.

Staff told us leaders and managers were approachable and supportive, and all staff we spoke with understood their roles and responsibilities. Regular appraisals were carried out, and staff had access to relevant policies and procedures.

Practice meetings were held regularly to discuss clinical concerns and emerging risks. Actions were recorded and shared with teams, supporting continuous learning and improvement. Staff took confidentiality and information governance seriously, and appropriate systems were in place to protect patient information.

Leaders acknowledged the areas for improvement and had begun taking steps to strengthen governance arrangements to ensure full oversight of safety, supervision and compliance requirements.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

The provider worked with other practices within their primary care network to offer extended access, and flu and covid vaccination programmes. The practice maintained positive relationships with community health and social care teams, including its aligned care home.

The service also gathered feedback from its patient population to support service improvement. A patient survey carried out between April and May 2025 received 109 responses. Findings showed high levels of satisfaction: overall, 90% of respondents rated their experience positively and 82.5% said they would recommend the practice.

The practice recognised the importance of continuous learning and improvement to enhance patient care and service delivery. While no formal innovations or research projects had taken place recently, the practice had completed a range of quality improvement activities to support ongoing development. For example, a new urinary tract infection (UTI) pathway had been implemented to improve clinical signposting and reduce demand on GP appointments.

A GP also acted as a mentor for the Frailty Nurse to support and supervise their competency for their non‑medical prescribing role. This included clinical discussions related to prescribing for patients, helping to ensure safe and consistent practice.

Complaints and significant events were reviewed by the team to identify opportunities for improvement and ensure that learning was shared across the practice.

Structured tools, such as the patient survey, were used to gather patient feedback and support reflection on patient experience. Staff were also encouraged to contribute ideas for improvement during regular practice meetings, which provided a space for open discussion and shared learning.

An example of this collaborative approach involved reviewing the management of patients prescribed weight‑loss medication who were also taking oral contraceptives or oral progesterone as part of hormone replacement therapy (HRT). Clinical discussions highlighted that this medication could affect the absorption of these treatments. As a result, the practice agreed that, if private providers informed the practice that a patient was using weight‑loss medication alongside these medicines, a text message would be sent to ensure the patient received appropriate advice.