Briercliffe Surgery

We carried out an announced inspection at Briercliffe Surgery on 8 June 2022. Overall, the practice is rated as good.

We rated each key question as follows:

Safe - Good

Effective -Good

Caring- Good

Responsive - Good

Well-led – Good

This was the first inspection of this GP practice under this registered provider.

Why we carried out this inspection.

This inspection was a comprehensive rating inspection where we reviewed all five key questions.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This included:

1. Conducting some staff interviews using video conferencing as well as face to face
2. Completing clinical searches on the practice’s patient records system and discussing findings with the provider
3. Reviewing patient records to identify issues and clarify actions taken by the provider
4. Requesting evidence from the provider
5. A site visit

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 have rated this practice as good overall

We found that:

• The practice implemented a comprehensive strategy with supporting business plans that reflected their vision and values to deliver a safe, effective and stable service to its patients.
• A cycle of continuous clinical audit and quality improvement that been commenced and this provided a framework and structure to monitor safety and effectiveness. The assurance frameworks incorporated all aspects of practice activity and aligned with the practice strategy and improvement agenda.
• A stable permanent staffing structure had been created and there was a commitment by all the practice staff to deliver a quality service.
• The weekly clinical meeting was used to support clinical learning and development. Each clinician including practice nurses were encouraged to bring a ‘case’ to the meeting to review the health care need alongside best practice guidance and treatment options
• The management team recognised and listened to the comments from members of the practice patient participation group (PPG) who identified gaps in the delivery of the service. The practice worked with the PPG to identify where and how improvements could be made to the service and an action log was completed. PPG minutes and the action log were easily accessible from the practice website.
• The culture of the practice fostered learning and development where all incidents, complaints and patient feedback were viewed as opportunities to learn, develop and improve.
• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• The practice was awarded the Safe Surgery certificate in March 2022. This meant the surgery was committed to removing barriers encountered by many vulnerable or marginalised people when trying to access and register with primary health services.
• Patients received effective care and treatment that met their needs. A comprehensive catch up plan targeting those patients who had reduced clinical monitoring in accordance with guidance during the pandemic was well established and advanced.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
• Patients could access care and treatment in a timely way.

We noted one area of outstanding practice:

• Despite the demands imposed on primary care by the pandemic restrictions and delivering the COVID-19 vaccination programme the practice was committed to working collaboratively with the PPG to improve patient experiences of the service they provided. Four face to face PPG meetings between May 2021 and February 2022 had been undertaken and actions implemented. These included redesigning the practice website, facilitating a patient led support group and providing an improved telephone system.

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