De Beauvoir 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

There was a proactive and positive safety culture, underpinned by openness and honesty. Safety concerns were actively heard, and incidents were investigated and appropriately reported. Lessons learned were used to inform and embed best practices across the service. Emergency management processes were in place, and safety‑netting measures were integrated into the triage system to help mitigate clinical risks. Where concerns were identified, the provider acted promptly to rectify the situation. Infection prevention and control were consistently monitored, with timely and appropriate actions taken to safeguard individuals. The premises and equipment were safely maintained, and safe recruitment practices were consistently followed. A structured learning and development programme supported staff in upholding high standards of safety and care.

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 fostered a proactive and positive safety culture, grounded in openness and honesty. Staff listened actively to safety concerns, and incidents were investigated and reported appropriately. Lessons were learned and used to continuously identify and embed good practice.People felt supported in raising concerns and described staff as compassionate and understanding. Managers promoted openness, and staff felt confident speaking up when things went wrong. Clinical issues were discussed during team meetings, encouraging shared learning and continuous improvement.Safety was consistently treated as a top priority, supported by clear processes for reporting incidents, near misses, and safety events which included a significant event log and protocol. Complaints were systematically recorded and investigated, and when things went wrong, staff offered apologies and support. Learning from incidents and complaints led to meaningful changes that improved the experience of others.

The service worked collaboratively with individuals and healthcare partners to establish and maintain safe systems of care, where safety was actively managed and monitored. Efforts were made to ensure continuity of care, including during transitions between different services.

The national GP patient survey conducted between December 2024 and April 2025 received 99 responses. Of these, 97% of patients reported being involved as much as they wanted to be in decisions about their care and treatment, and 93% felt their needs were met.

Leaders and staff reported that a designated team was responsible for managing referrals through the NHS e-Referral Service. Staff monitored the system to ensure referrals to specialist services were accurately documented, included the correct information, and were processed without delay. Safety netting procedures were in place to ensure all patients were appropriately followed up. Routine referrals were monitored to confirm whether patients still required specialist input or if their condition had deteriorated.

Leaders also explained that they maintained oversight of workflow tasks to ensure timely responses. A system was in place to summarise patient records effectively.

Monthly multidisciplinary team (MDT) meetings were held to review and improve outcomes for people with complex needs; alongside separate monthly MDT meetings focused on child and adult safeguarding. The local Integrated Care Board confirmed that they had no concerns about the service.

The service demonstrated a commitment to taking immediate action to protect people from abuse and neglect, working collaboratively with partners to achieve this. A safeguarding GP lead, safeguarding GP deputy, and administration lead were in place; all of whom reported being allocated time to review patients where safeguarding concerns had been identified. Internally, staff met monthly to review such cases, and the service actively monitored children who were not brought to appointments. Staff were aware of the appropriate channels for reporting safeguarding concerns.

Staff worked with individuals to understand and manage risks holistically. They delivered care that was safe, supportive, and tailored to meet people’s needs, enabling them to engage in activities that mattered to them.

Emergency equipment was available and appropriately maintained; however, we noted that the emergency drug bag did not have a tamper seal. In addition, no antibiotic was stocked for the immediate pre‑hospital management of suspected sepsis. However, the provider acted promptly to purchase the medication and ensure it was available on-site before the end of the assessment. Emergency bag tamper seals were also ordered by the provider.

Staff were able to recognise when a patient’s condition was deteriorating and understood the appropriate actions to take. Patients were advised about risks related to their condition and were given guidance on what to do if their condition worsened.

The service had a comprehensive business continuity plan that addressed various risks, including fire, flooding, loss of computer or telephone systems, and staff shortages.

During our on-site assessment, we observed that the premises was clean, well maintained, and conducive to safe care. The service had effective systems in place to monitor and comply with mandatory risk assessments, including fire safety and legionella testing, which helped ensure the safety of both patients and staff. Records confirmed that medical equipment was regularly maintained, calibrated, and tested.A business continuity plan was in place and was regularly reviewed and monitored to ensure the service remained prepared for potential disruptions.

The service ensured there were sufficient qualified, skilled, and experienced staff who received effective support, supervision, and development. Staff worked well together to deliver safe care that met people’s individual needs.A range of clinical and non-clinical roles were present within the service. Firstly, it was noted that one member of the administrative team had not completed the required equality and diversity training, as stipulated by the service’s training policy. In response, the provider acted promptly to ensure the staff member enrolled in and completed the necessary course.Secondly, a review of a locum doctor’s file revealed an incomplete record of mandatory training. The file lacked documentation for essential modules, including the Mental Capacity Act, Information Governance, Fire Safety, and Infection Control. During discussion, the provider acknowledged the challenge of obtaining training records for locum staff. However, they noted that their current recruitment process for GP locums includes a system to specify mandatory requirements, and that evidence of completion could be uploaded for approval prior to engagement. This feature had not been fully utilised, which meant the provider was unable to demonstrate that GP locums had completed the necessary training.Staff development and learning needs were appropriately managed, and individuals worked within their agreed areas of competence. Safe recruitment practices were followed.Staff reported feeling supported by the leadership team and felt their views were listened to.

Patients we spoke with told us they found the service clean and tidy and had no concerns relating to Infection Prevention and Control (IPC).The service had a designated IPC lead, and all staff had received relevant training. Cleaning schedules were in place and followed consistently. Risk assessments and audits were completed, with actions taken to mitigate identified risks.We noted that the service’s IPC policy did not specify training requirements for different staff groups. However, staff had received appropriate training, and the policy was updated following the assessment.

Leaders described the service's processes to ensure appropriate clinical oversight and told us how they monitored patients' health, including their use of high-risk medicines (such as warfarin, methotrexate, and lithium). We found that staff had good knowledge of current and relevant best practice and professional guidance.

There was an effective system to evidence the competence of non-clinical medical prescribers, including clinical supervision. The service had appropriate policies and procedures to govern prescribing effectively. The provider held regular GP clinical meetings to discuss patient cases, share knowledge about new medical information, review clinical practices, identify areas for improvement, and ultimately enhance the quality and safety of patient care.

Staff received training in medicines management and reported feeling confident in handling the storage, administration, and documentation of medicines. They held the necessary authorisations to administer medicines, including Patient Group Directions and Patient Specific Directions. Medicines-related stationery was managed securely, and staff followed established protocols to ensure safe prescribing practices.

The service ensured that medicines and treatments were safe, person-centred, and aligned with individuals’ needs, capacities, and preferences. People were actively involved in planning their care, including when changes to their medicines occurred. Staff supported patients in understanding and managing their medicines safely and knew who to contact if their condition worsened or unexpected symptoms arose.

Staff were regularly trained and assessed for competency in medicines optimisation. Prescription stationery was stored securely, and medicines, were kept at appropriate temperatures. Stock levels and expiry dates were routinely checked.

The provider had robust systems in place to manage safety alerts and medicine recalls. Staff took proactive steps to ensure prescribing was appropriate and aimed at optimising care outcomes, including the responsible use of antibiotics. Prescribing data reviewed during the assessment supported this, showing that the provider issued fewer antibiotics, hypnotics, anticonvulsants and psychotropics compared to local and national averages.

A programme of regular clinical audits focused on prescribing practices, aiming to continuously improve care and treatment. For example, we reviewed a cancer diagnosis audit carried out by the service between 2024 and 2025, in which the service examined routes to diagnosis, timeliness, adherence to guidelines, and opportunities for learning.

There was no evidence of systemic failure. Most cancers were identified promptly via screening, appropriate testing, and clinician vigilance. We also reviewed the service’s latest audit of all quinolone prescriptions issued between July 2024 and July 2025. Forty-six prescriptions were issued, the majority were for guideline-appropriate indications, but a minority were used where first‑line antibiotics should have been preferred. Documentation standards were reasonably good but with notable gaps. The provider noted that, compared with the prior year, adherence to prescribing guidelines had improved. Further actions were identified to strengthen documentation, patient counselling, and antimicrobial stewardship, with a re‑audit scheduled for the following year to assess progress.

As part of the assessment, a series of clinical record searches were carried out by a CQC GP Specialist Advisor, with the provider’s consent. These searches aimed to assess whether the service was delivering care and treatment in line with current legislation, standards, and evidence-based guidance.

Following the assessment, the provider assured us that they had contacted the patients identified during our clinical searches.