Updated 13 March 2026
Date of Assessment: 10/07/2026 to 20/07/2026 2026. Riverbrook Medical Centre is a GP practice and delivers service to approximately 9717 people under a contract held with NHS England.
The latest available data from the National General Practice Profiles, states that the ethnic make-up of the practice area is 69% White, 16% Asian, 6% Mixed, 6% Black and 3% other. Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the fourth decile (4 of 10). The lower the decile, the more deprived the practice population is relative to others. This assessment considered the demographics of the people using the service, the context the service was working within and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report.
We carried out an announced comprehensive assessment of all 5 key questions (Safe, Effective, Caring, Responsive and Well-Led). Remote clinical searches were carried out on 10 July 2026, and the site visit was on 13 July 2026.
The service demonstrated a positive learning culture where staff felt able to raise concerns, and managers investigated incidents thoroughly and promoted learning from events. However, people were not always protected from the risk of harm. We identified concerns relating to medicines reviews, record keeping, and infection prevention and control (IPC) arrangements, including the absence of a comprehensive IPC policy.
Staff understood and managed risks appropriately. The premises and equipment were suitable for the delivery of care, clean, and well maintained. There were sufficient numbers of staff mostly with the appropriate skills, qualifications and experience to meet people’s needs. However, not all staff had completed the required mandatory training and the system in place to monitor compliance did not always highlight this. Regular appraisals and supervisions to support the delivery of safe, high-quality care did not take place according to the providers own policy. Not all of the recommended emergency medicine were readily available with no risk assessment to explain the decisionmaking.
People were involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. Staff worked with all agencies involved in people’s care for the best outcomes and smooth transitions when moving between different services. Staff made sure people understood their care and treatment to enable them to give informed consent. Staff involved those important to people and took decisions in people’s best interests where they did not have capacity. However, we found that the service’s approach to promoting immunisation uptake and cancer screening was not sufficiently proactive or effective.
People were treated with kindness and compassion. Staff protected their privacy and dignity. They treated them as individuals and supported their preferences. People had choice in their care and treatment. The service supported staff wellbeing.
People were involved in decisions about their care. The service provided information people could understand. People knew how to give feedback and were confident the service took it seriously and acted on it. The service was not easy to access by telephone. They worked to eliminate discrimination. People received fair and equal care and treatment. People were involved in planning their care and understood options around choosing to withdraw or not receive care.
Leaders and staff had a shared vision and culture that promoted openness, learning and continuous improvement. Staff told us they felt supported to raise concerns and provide feedback, and there was a positive culture of teamwork and communication, supported through weekly staff meetings. Staff understood their roles and responsibilities, and leaders were visible and approachable. The service engaged with the local community and demonstrated a willingness to adopt new ideas to improve the quality of care provided. However, we identified concerns regarding the effectiveness of the provider’s governance arrangements. Risk assessments were not always comprehensive, and there were weaknesses in the provider’s oversight of environmental risks, staff training and regulatory compliance. During the assessment, we found that systems and processes for assessing, monitoring and mitigating risks relating to people’s health, safety, welfare, privacy and dignity were not always effective. Audits and quality assurance processes had failed to identify a number of concerns found during our inspection, indicating that governance and oversight arrangements were not sufficiently robust to ensure risks were consistently identified, monitored and addressed.
We found breaches of regulation in relation to regulations 12 and 17. We have asked the provider for an action plan to address the concerns found at this assessment