Browney House Surgery

On this page

• 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

We looked for evidence that people were protected from abuse and avoidable harm.

This is the first inspection for this service since its registration with CQC. This key question has been rated as good.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety.

People felt supported to raise concerns and reported that staff treated them with compassion and understanding. Managers promoted a culture of openness and encouraged staff to speak up when things went wrong. Clinical issues were discussed as a team during staff meetings, creating opportunities for shared learning.

The provider maintained a structured process for recording and investigating incidents and complaints. When things went wrong, staff apologised and supported those affected. They discussed learning from incidents in team meetings and implemented changes to improve care. For example, after receiving a complaint about the lack of a confidential space at reception, staff raised the issue during a meeting and acted by displaying signage to encourage patients to request privacy when needed.

To further strengthen reporting, the service introduced a dedicated task group in July 2025. Staff sent tasks to this group rather than only to the practice manager, ensuring that reports were not missed and could be recorded and actioned in a timely way. The lead GP and business manager also had access to the group, providing continuity and oversight when the practice manager was on leave or absent.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was actively managed and monitored. Staff ensured continuity of care, including when patients moved between services, through clear processes for handling clinical information and referrals.

Incoming documents such as hospital discharge summaries and clinic letters were initially received by the Practice Manager and signposted to the Practice Pharmacist, who reviewed them and made any necessary medication changes. When the pharmacist was unavailable, documents were redirected to a GP to ensure timely action.

Referrals, including urgent and 2-week-wait (2WW) referrals, were managed by the practice secretary, who booked the appointment before the patient left the practice and later followed up to confirm that the patient had attended.

The service worked with its Primary Care Network (PCN) and other partners to support seamless care pathways. Patients could be directly booked into mental health appointments remotely, and the practice had access to a dedicated Social Prescriber who supported patients with non-clinical needs.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. However, some areas of safeguarding required improvement.

Formal multi-disciplinary (MDT) safeguarding meetings had not taken place since January 2025 due to the temporary unavailability of key safeguarding partners. While safeguarding remained a standing agenda item in weekly practice meetings, the formal MDT meetings were only recently re-established following their return.

We identified that a non-clinical staff member working on-site during opening hours had not completed Level 1 safeguarding training. Managers acknowledged this and confirmed that appropriate training would be arranged.

The provider’s safeguarding policies for adults and children initially listed the wrong safeguarding lead. We raised this with the provider, and we saw they promptly amended the policy.

Despite these concerns, most staff had completed safeguarding training appropriate to their role. Staff were clear on who the safeguarding lead was and reported they could access support when needed.

The practice had a chaperone policy in place to provide reassurance and mitigate risk for both patients and staff. Disclosure and Barring Service (DBS) checks were undertaken when required.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Emergency equipment was available and maintained. Staff could recognise a deteriorating patient and knew of action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated. Staff were trained in resuscitation. Although staff had not received formal mandatory training in sepsis, they were able to recognise the signs when asked. Following the site visit, the practice informed us that sepsis was subsequently added to the mandatory training programme.

The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

A fire safety risk assessment had been completed, and fire safety was discussed at the practice meetings, but fire drills had not been conducted. Additionally, there was no health and safety risk assessment for the branch site and there was no lone workers policy, which meant risk to staff working alone was not formally addressed or mitigated. There was also no pocket face mask available at the branch site, which could have impacted emergency preparedness.

Following the site visit, the practice took several steps to improve safety and compliance. A lone workers policy and a health and safety risk assessment for the branch site were provided. The practice informed us that fire drills will now be conducted and appropriately documented. They also confirmed that a pocket face mask had been purchased for use at the branch site.

The practice had a business continuity plan in place which was monitored and reviewed. The premises were accessible, with clinics located on the ground floor, The environment was secured with coded access, secure storage, visitor sign-in protocols, and confidential waste disposal arrangements.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Training was generally up to date, and staff development was well-managed. A new policy had been introduced to strengthen clinical supervision, including regular supervision sessions, case reviews, and competency checks for non-medical prescribers. While some gaps in mandatory training were identified, these were addressed, and systems were put in place to improve oversight and ensure ongoing compliance.

Appraisals were carried out to support staff development and maintain competence. The appraisal records we reviewed included reflective activities focused on learning from significant events and incidents. Although locum appraisals were not currently conducted, the practice was exploring options to implement them for long-term locums to ensure consistency and oversight.

The scope of the Advanced Nurse Practitioner (ANP) had been agreed within the team but was not formally documented, creating a risk of unclear clinical responsibilities and potential booking errors. Following the assessment, leaders confirmed that the scope would be formally documented and shared with administrative staff to support safe and effective appointment allocation.

The service did not always assess or manage the risk of infection effectively. There was no robust process in place to assure that all staff (clinical and non-clinical) were protected from infection through appropriate routine pre-exposure immunisation. This was not in line with guidance issued by the UK Health Security Agency, as outlined in the Green Book: Immunisation Against Infectious Diseases.

While Legionella monitoring was in place, the practice sent external water samples for testing, but there was no documented risk assessment.

The practice had a designated infection prevention and control lead, and all staff had received relevant training. Risk assessments and audits were completed, and actions were taken to mitigate identified risks. Cleaning schedules were in place and followed; however, they were not recorded as having been completed, which reduced assurance that cleaning was being carried out consistently and effectively. Following the site visit, the practice informed us that a cleaning log had been created to improve oversight.

The service had systems to ensure medicines were managed safely and met people’s needs, though some improvements were required.

Monitoring of high-risk medicines was not always in line with national guidance. For example, a small number of patients prescribed Direct Oral Anticoagulants (DOACs) had not received the recommended level of monitoring. In addition, follow-up systems for patients with long-term conditions, such as diabetes, were not consistently effective. One patient had been prescribed metformin despite a contraindication; this was stopped following a clinical review.

Documentation for pregnancy prevention in patients prescribed medicines that can cause harm in pregnancy (teratogenic medicines), such as Annual Risk Acknowledgement Forms (ARAFs) and Pregnancy Prevention Programmes (PPPs), was incomplete. However, we saw evidence during the site visit that the process had started, and work was underway to obtain the necessary documentation.

From the Medicines Optimisation (Prescribing) data covering the period from 1st October 2024 to 31st March 2025, received by the CQC from the NHS Business Services Authority (NHSBSA), we observed that the practice's antibiotic prescribing was above the national average. However, the practice was aware of this and was actively working to improve prescribing behaviours. Recent practice audits showed a 36.3% reduction in prescribing from April 2024 to March 2025.

The practice had systems for the safe management and storage of medicines, including vaccines, medical gases, appropriate emergency medicines and equipment. A pharmacist reviewed people’s medicines, discharge letters and clinic correspondence to ensure records were accurate and up to date. The Electronic Prescription Service was used to transfer prescriptions securely to the patients’ preferred pharmacies, and controlled stationery was tracked to maintain a clear audit trail.

Patient Group Directions (PGDs) were in date, signed and authorised.

The practice operated a dispensary for a small number of eligible patients under a dispensing doctor’s arrangement. Written procedures were in place, reviewed regularly, and staff signed to confirm compliance. The dispensary was overseen by a named GP, staffed by appropriately qualified personnel, and medicines were stored securely with restricted access. Staff described how they monitored patients’ medicines, including those used for long-term conditions, and offered advice and counselling to patients receiving medicines from the dispensary.

Dispensing incidents and near misses were recorded and discussed at practice meetings, with learning shared. There were effective processes to act on drug alerts and medicines recalls, and staff were able to describe how these were managed.

Following the site visit, the practice told us they had developed an action plan to address the above concerns. This included strengthening monitoring for high-risk medicines and improving recall processes.