The Care Quality Commission
  • Doctor
  • GP practice

Brereton Surgery

Overall: Good read more about inspection ratings

Main Road, Brereton, Rugeley, Staffordshire, WS15 1DU (01889) 575560

Provided and run by:
Brereton Surgery

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Brereton Surgery 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 Brereton Surgery, you can give feedback on this service.

11 December 2019

During an annual regulatory review

We reviewed the information available to us about Brereton Surgery on 11 December 2019. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.

25 April 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr N Sivanesan & Partners (known as Brereton Surgery) on 18 August 2016. The overall rating for the practice was good, and the well led domain rated as Requires Improvement. The full comprehensive report on the August 2016 inspection can be found by selecting the ‘all reports’ link for Dr N Sivanesan & Partners on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 25 April 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breach in regulation that we identified in our previous inspection on 18 August 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Our key findings were as follows:

  • The practice had developed a system to demonstrate that the medicines and equipment alerts issued by external agencies were acted upon. We saw for the two alerts received post April 2017 appropriate action had been taken.
  • The practice had improved the systems in place for assessing and monitoring. A range of risk assessments had been completed and action plans in place to manage the identified risks.
  • The practice had strengthened the governance procedures in place. A meetings schedule had been developed, set agendas were used and meetings minuted and the information shared with all staff.
  • The leadership structure was being updated due the changes in the partnership. The partners had designated managerial and clinical roles and met regularly to discuss the practice strategy.
  • The practice continued to develop the role of the patient participation group and the group now met in person.
  • Systems were in place to check the continued registration of nurses with their professional body. However, the practice did not ask for information relating to any physical or mental health conditions that the person may have, or whether they were up to date with their routine immunisations.

One area for improvement remained outstanding from the previous inspection:

  • Record information regarding any physical or mental health conditions that applicants may have.

Two additional areas for improvement have been identified. The provider should:

  • Ensure the practice are in receipt of all appropriate safety alerts and take appropriate action on any gaps noted in receipt.
  • Review whether staff are up to date with their routine immunisations and take appropriate action as required.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

18 August 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr N Sivanesan & Partners (known as Brereton Surgery) on 18 August 2016. Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients told us on the day of the inspection they were able to get appointments, both routine and emergency, although they may have to wait to see a GP of their choice.
  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events. However, there were inconsistencies in the level of detail recorded for significant events.
  • Risks to patients were not always assessed and well managed, because the immunisation status of staff was not recorded, a system was not in place for checking the nurses’ continued registration with their professional body, lack of assessments into risks such as fire, slips, trips and falls, non-servicing of the fire alarm, emergency lighting and stair lift.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • The practice did not have a clear leadership structure in place, as the GPs did not have designated clinical or managerial roles. However, staff told us they felt respected, valued and supported, particularly by the partners in the practice.
  • The practice sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the duty of candour.

The areas the provider must make improvements are:

  • Introduce a formalised system to act upon medicines and equipment alerts issued by external agencies.
  • Introduce a system to check the continued registration of the nurses with the appropriate professional body.
  • Carry out risk assessments into risks such as slips, trips and falls.
  • Introduce effective systems for identifying, recording and managing risks, issues and implementing mitigating actions.
  • Ensure that all equipment, including the fire alarm, emergency lighting and stair lift are serviced in line with the manufacturers' instructions.
  • Ensure there are formal governance arrangements in place including systems for assessing and monitoring risks and the quality of the service provision.
  • Develop a clear leadership structure, including designated roles and responsibilities for staff.

In addition the provider should:

  • Ensure that the records of significant events and the minutes of meeting contain the details of the discussion and lessons learnt.
  • Formalise the structure of meetings held at the practice through set agendas and detailed minutes.
  • Review and record the immunisation status of staff to establish if staff and patients are protected from the risk of health care acquired infections.
  • Record information regarding any physical or mental health conditions that applicants may have.
  • Record which staff attend fire drills and how long it takes to evacuate the building.
  • Consider keeping a copy of the business continuity plan off site.
  • Continue to develop the role of the patient participation group.
  • Consider a documented business plan to support the practice vision and future strategy.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice