We carried out a review of the data available to us about Beaumont Lodge Medical Practice on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Beaumont Lodge Medical Practice, you can give feedback on this service.
We carried out an announced comprehensive inspection at Beaumont Lodge Medical Practice on 09 August 2016. The overall rating for the practice was good, however the practice was rated as requires improvement for the provision of safe services. The full comprehensive report on the August 2016 inspection can be found by selecting the ‘all reports’ link for Beaumont Lodge Medical Practice on our website at www.cqc.org.uk.
This inspection was desk-based review carried out on 15 February 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 09 August 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.
Overall the practice is now rated as good.
Our key findings were as follows:
Clinical waste bins were stored securely and safely in a designated secured area.
The gas boiler had been serviced and an electrical installation safety check had also been carried out.
Written protocols were implemented to support reception staff in their duties around prescribing.
Significant events and safety alerts had been added as a standing agenda item for practice meetings.
A system was in place to check registration with the appropriate professional bodies for nursing staff and GPs.
Documentation for monthly checks on emergency lighting and fire exits had been updated to ensure emergency lighting was included.
A documented process was put into place to support the system in place to follow up children who did not attend for immunisations. This included telephone contact on the day, which was recorded in the patient record and a further appointment was booked for the following week.
The practice considered how to control noise to ensure conversations held in consultation and treatment rooms could not be overheard. The volume on the waiting room television had been adjusted which had resolved this.
The patient registration form was amended to include a carers section so patients could be identified on the patient record system accordingly. GPs were also encouraged to record patients on the system as a carer when they became aware. Leaflets regarding services for carers were also available in the waiting areas.
Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Beaumont Lodge Medical Practice on 09 August 2016. Overall the practice is rated as good.
Our key findings across all the areas we inspected were as follows:
There was a system in place to reporting and record significant events and action was taken to improve safety in the practice. However, we noted that written protocols were not in place to support reception staff in all of their duties following a trend of significant events.
Not all staff were aware of the lessons learnt following investigations of significant events.
Safety alerts were cascaded and actioned as appropriate, however there was no documented evidence to show the discussions between staff members.
The practice was observed to be clean and infection control audits were carried out. However, we noted that external clinical waste bins were not secured in line with Health and Safety Executive guidance.
The practice could demonstrate that all nursing staff and GPs were registered with the appropriate professional body, however had no system in place to ensure they renewed their registration on an annual basis.
Most risks to patients were assessed and managed. However, there was no documentation to reflect the monthly checks carried out on emergency lighting or fire exits.
An electrical installation safety check had not been carried out within the required timeframe in accordance with statutory requirements.
The gas boiler has not been serviced and maintained in line with manufacturer guidance and statutory requirements.
Staff assessed needs and delivered care in line with current evidence based guidance.
The practice used local prescribing guidelines to ensure prescribing was in line with best practice guidance.
Staff had the skills, knowledge and experience to deliver effective care and treatment.
Patients were supported to live healthier lives and the practice worked with the local police to ensure patients with a mental health illness were supported where appropriate.
The practice had a process in place to follow up any child that did not attend for their immunisations; however there was no written protocol to support this.
Patients said they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment.
We noted that conversations in consultation and treatment rooms could be overheard at times.
We saw staff treated patients with kindness and respect.
The practice identified carers at the point of registration to ensure they received the appropriate support, however there was limited numbers identified compared to the practice list size.
The practice had good facilities and was well equipped to treat patients and meet their needs.
Some patients told us they found it difficult to get an appointment for when they wanted it; however most patients were happy with the appointment system.
Information about how to complain was available and easy to understand. Staff knew how to support patients and learning from complaints was shared with staff.
The practice had a clear mission statement which included the values for the practice ensuring they were open and honest with patients, providing safe care.
The provider was aware of and complied with the requirements of the duty of candour. The partners encouraged a culture of openness and honesty.
The patient participation group was active and worked closely with the practice management team.
We saw one area of outstanding practice:
A template had been designed to work with Leicester Police. The police notified the practice of any incidents where the patient may have a mental health illness to ensure the GPs were alerted and additional support was provided, as appropriate. The practice were able to demonstrate what action they had taken as a result, including a telephone call to the patient or amending personal care plans in line with other relevant health and social care professionals.
The areas where the provider must make improvement are:
Ensure clinical waste bins are stored securely in line with Health and Safety Executive guidance.
Ensure an electrical installation safety check is carried out within the required timeframe in accordance with statutory requirements.
Ensure the gas boiler is serviced and maintained in line with manufacturer guidance and statutory requirements.
The areas where the provider should make improvement are:
Consider implementation of written protocols to support reception staff in their duties around prescribing.
Review the process in which all staff are informed of lessons learnt from significant event investigations.
Review the process to document discussions regarding safety alerts.
Consider the implementation of a process to review annual registration with the appropriate professional bodies for nursing staff and GPs.
Review the process to document monthly checks on emergency lighting and fire exits.
Consider implementation of a documented process regarding the follow up of children who do not attend for immunisations.
Consider how to control noise, specifically conversations held in consultation and treatment rooms.
Consider the process to identify carers and how carers could be identified.
Chief Inspector of General Practice