Browney House Surgery

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture

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

The service was in breach of legal regulation in relation to good governance.

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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff told us there was an open and honest culture within the practice. They felt confident to raise concerns without fear of retribution and believed that their views were listened to and valued. Staff also said that there was a clear vision for the future.

However, some staff noted that they had not been involved in the development of the practice’s strategic planning, including the creation of its mission statement, vision, and values.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation.

Staff told us leaders in the practice were approachable and responded to any concerns raised.

The practice worked with the local Primary Care Network (PCN) and was actively engaged in PCN-led initiatives to improve patient care, including collaboration on medicines optimisation.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

The practice had established Freedom to Speak Up arrangements, and staff told us they knew how to raise concerns if needed. Most staff who responded to the feedback questionnaire confirmed that they understood what whistleblowing was and how to report concerns.

The service valued diversity in its workforce and worked towards an inclusive and fair culture by improving equality and equity for the people who worked there.

Staff received training in equality, diversity, and human rights, and reported feeling respected in their roles. Leaders promoted open communication and maintained an open-door policy to encourage feedback.

Staff shared examples of positive changes made in response to their feedback. These included the introduction of protected break times and the creation of a designated area where staff could take lunch away from their desks, supporting wellbeing.

The service did not always have effective governance systems to support oversight of risk, performance, and quality of care. For example, there was no robust system in place for managing staff immunisation status. Policies were not always reviewed in a timely manner; some contained incorrect named leads, and there was no lone working policy in place. Recruitment files for long-standing staff did not consistently contain documented proof of identity. Mandatory training records showed gaps in key areas such as sepsis and the Mental Capacity Act, and locum staff had not received appraisals. Fire drills had not been conducted, and there was no documented legionella risk assessment, although external water testing was in place.

Clinical oversight systems also required strengthening, although the number of patients affected was small. Some prescribing and monitoring arrangements were not always aligned with current guidance, and follow-ups were missed for a few patients requiring repeat testing. In some cases, medication reviews had been coded by non-clinical staff, which risked giving the impression that the reviews had been conducted by them. Upon investigation, it was confirmed that appropriate clinicians had completed the reviews, and this was documented in the patient records.

Documentation was inconsistent, with gaps in the recording of pregnancy prevention plans for patients prescribed high-risk medicines that can cause harm in pregnancy (teratogenic medicines), and DNACPR forms, which were not routinely scanned into patient records. During the site visit, leaders assured us that work to obtain the required documentation for patients on teratogenic medication was already in progress, though not yet complete. These issues limited assurance that clinical care was being consistently monitored and safely delivered.

Leaders had discussed the role of the Advanced Nurse Practitioner (ANP) but had not formally documented the scope of practice. This meant there was limited assurance that governance arrangements clearly set out responsibilities, accountability, and boundaries of clinical roles.

Following the inspection, leaders acted promptly and pro-actively submitted a comprehensive action plan. This included strengthening prescribing and monitoring systems, updating policies and training requirements and enhancing recall processes. The safeguarding policies were updated to reflect the correct lead, and a lone working policy was created and shared. These steps demonstrated a clear commitment to improving governance and ensuring more robust oversight.

Despite the initial gaps in governance, staff described the practice as a supportive place to work, and most felt well managed. Appraisals were held regularly, and practice meetings provided opportunities to discuss clinical issues and share learning. Leaders were open and responsive during the assessment and showed a commitment to strengthening oversight, improving safety, and enhancing the sustainability of the service.

The service understood its duty to collaborate and work in partnership, so services could work seamlessly for people. Staff shared information and learning with partners and collaborated for improvement.

The practice engaged positively with external partners to meet the needs of its patient population and worked closely with its Primary Care Network (PCN), including participation in medicines optimisation initiatives and other shared clinical priorities.

The practice had an active Patient Participation Group (PPG) and sought ways to improve patient engagement. Between April 2024 and March 2025, the Friends Family Test (FFT) received a total of 42 responses, which is recognised as a low response rate. To improve this, the Practice Manager explored options to link the FFT survey to appointment confirmations, allowing patients to receive a prompt to complete the survey following their visit.

Multidisciplinary team (MDT) meetings were held regularly to support collaborative care planning and ensure continuity of care. These included meetings focused on palliative care, diabetes, and safeguarding.

Although there was a gap in safeguarding meetings from January until recently due to key safeguarding partners being unavailable, safeguarding oversight was maintained. Staff told us that safeguarding concerns were discussed in weekly practice meetings when required, ensuring continued attention to patient safety.

These processes enabled the practice to work closely with other professionals to support patients with complex or vulnerable needs.

The practice recognised the importance of continuous learning and improvement to enhance patient care and service delivery. While no formal innovations or research projects had taken place recently, patients were involved in service evaluation through the Patient Participation Group (PPG) and patient surveys. For example, the PPG raised concerns about the waiting area, and the practice explored options to improve the environment, although financial constraints meant changes were not taken forward.

Structured tools such as the Improving Practice Questionnaire were used to gather patient feedback and support reflection on patient experience. Staff were also encouraged to contribute ideas for improvement through regular practice meetings, which provided a space for open discussion and shared learning.

Complaints and significant events were reviewed by the team to identify areas for improvement and to ensure learning was shared across the practice. Staff appraisal records we reviewed included reflective activities focused on learning from significant events and incidents. This supported a culture of openness and accountability.

Digital tools were recently introduced to strengthen clinical processes, including system templates and alerts to support monitoring, diagnostic checks and recall systems. While these tools were designed to streamline processes and improve consistency in patient care, they had not yet been fully embedded at the time of the assessment, and their impact was still being evaluated.