Archived: The Brook Surgery

At the previous inspection 31 July 2018 was rated the practice as Requires Improvement overall and in the Safe, Responsive and Well-Led key questions. We carried out an announced follow-up comprehensive inspection at The Brook Surgery on 1 August 2019 to follow-up on previous breaches in regulation 12; Safe care and treatment, regulation 19; recruitment procedures and regulation 17; Good governance.

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.

At this inspection, although we saw significant improvements in the areas of concern from the previous inspection we have rated this practice as requires improvement overall, as the effective and responsive key questions were rated as requires Improvement. The practice is rated as requires improvement for all population groups as both the effective and responsive key questions were rated as requires improvement.

We rated the practice as Requires Improvement for providing effective services because:

• Cervical screening and childhood immunisation uptake data for the practice was below local and national averages. Cervical screening uptake data had declined since the previous inspection. The practice had begun a programme of quality improvement activity in this area in the form of audits and the new data, provided by the practice indicated that there may be some improvement beginning.
• Childhood immunisation data was lower than averages. The practice provided us with recent childhood immunisation data that related to the first quarter of 2019. This data did not indicate that there was an improvement overall.

We rated the practice as Requires Improvement for providing responsive services because:

• The practice offered their patients seven-day access to care and treatment, either through themselves or through the federation but were unable to yet demonstrate that data relating to patient satisfaction with access to care and treatment had improved. Although the practice had run their own survey, there was no formal analysis of the results and questions asked did not fully reflect the questions asked on the national GP patient survey. Although this provided some indication that patient satisfaction had begun to improve, the practice acknowledged that there was still work to be done.

We rated the practice as Good for providing safe, caring and well-led services because:

• The practice responded immediately and proactively to the identification of concerns relating to the lack of monitoring of vaccines and has taken steps to address this including engaging with Public health England (PHE), the Clinical Commissioning Group (CCG) and employing a dedicated member of staff to ensure oversight of this and train staff.
• We saw that staff dealt with patients with kindness and respect and involved them in decisions about their care. This was aligned with feedback received from the practices in-house survey.
• The practice had made improvements to strengthen governance oversight and there was a commitment to continuous learning

The areas where the provider should make improvements are:

• Continue to strengthen the governance arrangements across both sites
• Continue to take steps to monitor and improve patient satisfaction in relation to access to care and treatment and continuity of care.
• Continue to take steps to improve cancer screening and childhood immunisation results.
• Continue to monitor systems established to ensure medicines are stored safely.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care