Brewood Surgery

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• 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

As part of our assessment, we reviewed policies, procedures, spoke with staff and undertook observations across all 3 sites. We completed remote clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements). We found the practice had gaps in some systems and processes to keep people safe. Learning was shared effectively and used to make improvements.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The evidence we reviewed did not show any concerns about people’s experience regarding learning culture at this practice. The PPG reported that patients were encouraged and supported to raise concerns and complaints. Three patients had reported to the CQC delays in the practice responding to complaints. Patient feedback was shared with leaders who advised at the practice annual general meeting (AGM), that patients who had not had their complaints addressed in a timely manner, to recontact them for these to be addressed. Leaders acknowledged there had been a period between practice managers when not all complaints had been documented and therefore may not have been addressed.

Staff we spoke with demonstrated an understanding of the procedure for reporting concerns and safety incidents and had access to a significant event policy. They were able to share examples of recent significant events raised, the outcomes and learning. Staff advised they received feedback at meetings or on a 1:1 basis regarding significant event investigations and learning. Staff told us they felt confident that they would be treated with compassion and understanding if they raised any concerns. Staff recognised that by raising concerns early that these could assist the practice to identify and manage risks before safety events happen. Leaders acknowledged there had been a period between practice managers when not all complaints had been documented and therefore may not have been addressed.

There was a complaints and significant event policy and log. Following feedback the practice updated the CQC on the actions taken on a specific medicine safety alert. We saw some good examples of quality improvement audits. For example, a review of the practice document management system, the outcome following the audit showed an improvement in the total number of letters awaiting to be scanned from 4000 to 12. It was acknowledged there had been a period between practice managers when not all complaints had been documented. Following our feedback the practice provided an up-to-date version of their complaints policy. This included the contact details of external bodies should complainants not be happy with the outcome of their complaint. Our clinical searches found 5 patients were outstanding a review of medicines, however these patients had since been recalled. Two of the sites offered an induction hearing loop to assist patients who were hard of hearing. Arrangements were in place to support patients whose first language was not English. Double appointments were available to ensure that patients with accessible information communication needs had sufficient time allocated during their consultation. Patients could receive communication support in the format they required. Staff had completed training to support autistic people and people with a learning disability. Incidents were appropriately investigated and reported. Lessons were learnt from safety incidents or complaints, resulting in changes to improve care for others.

The evidence we reviewed did not show any concerns about people’s experience regarding safe systems, pathways, and transitions at this practice. With the exception of a few patients who mentioned the systems for repeat prescribing.

Staff reported they were confident and comfortable to speak up and raise concerns however, not all staff were familiar with the named freedom to speak up guardian. Staff reported positively on the practice’s emphasis on their safety and well-being. Staff we spoke with, and the clinical searches demonstrated a collaborative, joined-up approach to safety that involved the patient, staff, and other partners in their care. Staff told us shared care agreements were in place for patients with long term conditions and medicines management as well as those requiring urgent referrals. Staff reported they had lead or joint roles within the work flow systems such as admission and discharge letters and information where people move between services.

The practice had a consent policy in place. The practice described their working arrangements with local practices within their Primary Care Network (PCN) to which the lead GP was the Clinical Director. The practice worked with a range of external agencies to ensure continuity of care for their patients and held a variety of regular meetings. The local care home was in receipt of regular visits from a designated practice team member. The practice had contacted the local GP Supporting General Practice Team and NHS England complaints team to assist them to review their systems and processes. The practice senior GP partner had regular contact with the Integrated Care Board (ICB) managers and attended ICB scheduled engagement meetings and chaired the ICB Primary Care IT collaborate board. The practice attended regular PCN meetings which enabled shared learning. The practice staff had access to a lone working policy, and training on whistleblowing, bullying, harassment and conflict resolution. They had effective systems to proactively manage urgent referrals. We found that care was planned and organised with patient involvement. However, the practice had not always followed national guidance for following up a monitoring blood test used in diabetes with the repeat blood test within 2 to 12 weeks. Our clinical searches identified historic patient safety alerts had not always been followed reviewed and actioned.

Staff reported they had been in receipt of training and were able to recognise the signs of abuse. Staff told us they knew how to raise a safeguarding concern and all but 1 member of staff reported they were aware of the practice safeguarding lead.

We received no concerns from external agencies about safeguarding for this practice.

There were effective systems and processes in place to make sure people were protected from abuse and neglect. All staff had received safeguarding training to a level appropriate to their role. The practice had reconciled its safeguarding registers with the local safeguarding team. Staff worked collaboratively to identify vulnerable patients and those who may be at risk of harm. Staff training oversight was not straightforward as some training was completed online and others face to face or through professional external courses. This meant that staff training appeared as out of date or overdue on their electronic systems, which may or may not be accurate. The practice needed to develop a failsafe process to maintain ease of training oversight.

The evidence we reviewed did not show any concerns about people’s experience for this quality statement.

Staff and leaders told us they understood the requirements of the legislation guidance when considering consent and decision making. Staff reported they were trained in basic life support and receptionists were aware of actions to take if they encountered a deteriorating or acutely unwell patient. Staff reported they had guidance in place on identifying such patients.

Training in the Mental Capacity Act and equality and human rights legislation was available for staff in addition to training to support autistic people and people with a learning disability. Staff had access to a consent policy which reflected national guidance to support children under 16 and adults that lacked capacity to make decisions about their care and treatment. A policy was in place to support ‘Do not attempt cardiopulmonary resuscitation (DNACPR)’ decisions where possible. No issues were identified in relation to patient group directions. The practice discussed cases in meetings to share risk and lessons learned, the practice also undertook quality improvement audits. The practice held the suggested medicines in the event of a medical emergency, with the exception of the Coven site. This was discussed with the provider, and we shared this information with the ICB following our site visit.

The provider had not been able to gain assurances from the landlord at the Coven site regarding health and safety assessments. Therefore effective arrangements were not in place for all sites in order to monitor safety and upkeep of the premises. These included gas, electrical safety, fire, legionella and health and safety audits and infection, prevention, and control. There were effective systems in place for the other 2 sites, with the exception of a gas safety certificate for Wheaton Aston. The Brewood and Wheaton Aston sites provided automatic doors and a level access. Car parking was available outside the main and Coven sites.

At the Coven site we observed a lack of cleaning schedules and handwash facilities in the consulting room. Despite staff advising they understood the actions to take in the event of an emergency we saw there was a lack of effective systems in place at the Coven site. The fire exit door detailed on the fire escape route plan was locked and staff had no access to keys. A health and safety audit at the main site had been carried out in February 2024 and we noted that the action plans were either in progress or completed whilst we were on site. A health and safety audit carried out at the Wheaton Aston site in February 2024 identified the need for an asbestos survey to be undertaken and this had been requested. Evidence for the calibration and testing of medical devices and portable appliance testing was available for all the 3 sites. Some equipment during our observations did not have the appropriate date stamp labels. It was brought to the providers attention, and they agreed to action.

The provider did not have effective arrangements in place for all sites to monitor the safety and upkeep of the premises. They had not gained assurances from the landlord at the Coven site regarding health and safety assessments. These included gas, electrical safety, fire, legionella and health and safety audits and infection, prevention, and control. There were effective systems in place for the other 2 sites, with the exception of a gas safety certificate for Wheaton Aston. The Brewood and Wheaton Aston sites provided automatic doors and a level access. Car parking was available outside the main and Coven sites.

The PPG had no concerns in respect of people’s experience regarding safe and effective staffing with the exception of some staff turnover. The National GP Patient Survey 2023 results for the practice showed that people were treated with care, were listened to, and had confidence in staff. The practice results were above local and national averages, including recognising and understanding people’s mental health needs. Prior to the assessment we received information of concern in relation to the Coven site and patient access to GP services. This was reported to the practice leaders and discussed at the PPG Annual General Meeting (AGM) with patients who attended. AGM meeting minutes were made available, and the practice had also shared patient feedback with the ICB.

Staff told us they were in receipt of effective support, supervision, and development to deliver safe care. Leaders told us they ensured the appropriate mix of staff were employed to ensure patients received good quality care to meet their needs. Staff reported there had been a turnover of reception staff, but most considered staffing levels were now adequate. Staff told us they have adequate time to complete training and were supported with their learning and development needs. Staff reported they had sessional debriefs and commented on the ease of access to clinical support. Leaders told us policies were in place to support performance management.

The practice had a policy in place for the safe recruitment of staff. However, we found not all the required recruitment checks had been carried out. We saw there were omissions in staff recruitment records. This included full employment histories and disclosure and barring service (DBS) checks had not been obtained prior to all staff commencing work. A risk assessment had been completed for some staff, however these were not dated and did not mitigate all potential risks. New staff had access to an induction programme to support them in their work. However, completed checklists were not available on all staff records. In general, staff had an annual appraisal supported by a personal development plan, this included the salaried GPs. However, we saw no formalised competency reviews of those with extended roles. For absence and sick leave staff utilised a team approach to provide cover. The practice had considered its future workforce and had developed a succession plan.

The evidence we reviewed did not show any concerns about people’s experience for this quality statement.

Staff told us that they had received training in infection, prevention and control (IPC) and had access to a designated IPC lead. Staff reported they had no concerns in relation to IPC.

The practice had IPC processes in place and had completed an annual infection, prevention and control (IPC) statement January 2023/24. IPC facilities were available across the main site and Wheaton Aston site. The Coven site was managed by the providers of the Coven Memorial Hall. There were no cleaning schedules seen and no handwash facilities in the consulting room.

Prior to our assessment we received information of concern in relation to allegations of prescribing errors and on the management of repeat prescriptions. The PPG told us that during the Annual General Meeting (AGM) the provider had shared their audit on prescription errors and complaints.

Staff and leaders told us they had systems and processes in place to support the safe prescribing of medicines. Staff reported they were involved in supporting patients in decisions about their medicines during reviews and assessments. The dispensing team told us they worked across the practice dispensary and the local community pharmacy service. Dispensing staff told us they had access to standing operating procedures for the dispensary.

The practice offered a dispensary delivery service, two delivery drivers were employed, however, we found this had not been fully risk assessed for safety, security, confidentially and traceability. In addition, we found these staff members had not received any medicine’s awareness training. This was fed back to the provider at the time of the site visit. We saw no oxygen was available at the Coven site and there was no rebreathe bag or face mask to assist with resuscitation. The provider explained that they had considered a range of options, but these were not practicable and/or had health and safety implications for the staff themselves such as staff carrying oxygen or equipment in their cars. They could not store the equipment at the Coven site.

There was a process for the safe handling of requests for repeat medicines and evidence of medicines reviews for patients. Blank prescriptions were kept securely, and their use was monitored in line with national guidance. The practice could demonstrate that staff with extended roles had access to debriefing and clinical support as a regular review however, this was not formalised. The practice pharmacy and dispensing team held regular meetings. We found that staff had good knowledge of current and relevant best practice and professional guidance. However, our clinical searches identified improvement was needed when staff completed medication reviews by applying historic medicine safety alert awareness.

Our clinical searches found processes were in place for monitoring patients’ health including clinical review prior to prescribing. However, we found gaps in the monitoring of some long-term conditions and medication reviews. The provider had actioned most of these shortfalls prior to our onsite visit.