04 May 2023
During an inspection looking at part of the service
We carried out a short-notice, focused inspection at Beaumont Park Surgery on 4th May 2023. The practice remains rated good overall.
We previously inspected the practice on 8 December 2016. At that time, the practice was rated good overall and for each of the five key questions.
This inspection included an on-site inspection and looked at the key question is the service safe. We have rated the practice as requires improvement for safe. This was in line with our published methodology to limit ratings at the key question level where we have identified a breach of regulations. Overall, the practice remains rated good.
Safe - requires Improvement.
Effective - not inspected, rating of good carried forward from previous inspection.
Caring - not inspected, rating of good carried forward from previous inspection.
Responsive - not inspected, rating of good carried forward from previous inspection.
Well-led -- not inspected, rating of good carried forward from previous inspection.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Beaumont Park Surgery on our website at www.cqc.org.uk
Why we carried out this inspection
This was an urgent focused inspection. We have carried out this inspection because we received information of concern relating to infection control issues at the practice.
How we carried out the inspection
This inspection was carried out by 2 CQC inspectors who visited the practice after a short-notice announcement.
This included:
- Observing the practice.
- Reviewing evidence of policies and documents in line with the ‘Safe’ domain.
Our findings
We based our judgement of the quality of care at this service on a combination of:
- what we found when we inspected.
- information from our ongoing monitoring of data about services and
- information from the provider, patients, the public and other organisations.
We found that:
- At this inspection we found that the practice did not have an infection prevention and control lead in place.
- We found that there was a lack of infection control audit activity being carried out.
- There was limited information surrounding staff vaccinations; both pre-employment and once employment had commenced. For example, Covid-19 and Flu vaccinations.
- There was evidence that cleaning logs had recently been put in place and were now being used.
- Not all staff had received appropriate safeguarding training at the time of the inspection. Staff were also unsure who the safeguarding lead at the practice was.
- The emergency equipment was located in various places around the practice. Whilst a member of staff was checking the equipment was working, no system was in place for it to be checked in their absence. Other members of staff were unaware a system for administration staff to carry out checks on the defibrillator had been introduced.
- The waiting room and public spaces were clean and free from clutter.
- Staff who hadn’t been subject to a Disclosure and Barring Service (DBS) check had not been risk assessed to support this.
We found 1 breach of regulation. The provider must:
- Ensure care and treatment is provided in a safe way to patients.
In addition, the provider should:
- Review and improve processes and awareness around significant event reporting and the sharing of lessons learned as a result.
- Review and improve processes for the checking of emergency medicines and equipment, including formalising arrangements for this to carry on in the absence of designated people.
- Complete a risk assessment to support the decision not to carry out a Disclosure and Barring Service (DBS) check for any member of staff.
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA
Chief Inspector of Health Care