Brook Square Surgery

We carried out an announced comprehensive inspection at Brook Square Surgery on 22 – 24 August 2023. Overall, the practice is rated as Good.

Safe - Good

Effective - Good

Caring - Good

Responsive - Good

Well-led - Good

Following our previous inspection on 4 November 2019, the practice was rated Good overall and for all key questions.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Brook Square Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection following changes in regulatory history in line with our inspection priorities.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

• Conducting staff interviews using video conferencing.
• Completing 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).
• Reviewing patient records to identify issues and clarify actions taken by the provider.
• Requesting evidence from the provider.
• A short site visit.
• Staff questionnaires.

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 found that:

• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• Patients received effective care and treatment that met their needs.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• Patients could access care and treatment in a timely way following the introduction of a remote clinical triage system
• The practice had embedded systems in place to keep people safe and safeguarded from abuse.
• The senior management and leadership team ensured effective management at all levels to deliver high quality sustainable care.
• The practice had analysed the needs of the local community and adapted services accordingly. This included question and answer sessions on women’s health and becoming a veteran accredited surgery.
• The way the practice was led and managed promoted the delivery of high-quality, person-centred care.

Whilst we found no breaches of regulations, the provider should:

• Continue to monitor the new processes in place to ensure patient documents are managed in a timely way.
• Formally monitor the competence of non-medical prescribers.
• Improve the follow up of patients after an acute exacerbation of asthma.
• Take action to improve the uptake of children receiving immunisations and patients eligible receiving cervical cancer screening.
• Continue to monitor access to the practice following the implementation of the remote clinical triage system now in place.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care