River Brook Medical Centre

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We looked for evidence that staff involved people in decisions about their care and treatment and provided them advice and support. Staff regularly reviewed people’s care and worked with other services to achieve this.

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

This service scored 63 (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 did not always make sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

Feedback from people using the service was positive. People felt involved in any assessment of their needs and felt confident that staff understood their individual and cultural needs. However, we identified gaps in medication reviews and in managing medicines effectively which may limit the ability to accurately assess people's changing needs and ensure the support they receive remains appropriate and effective.

Reception staff were aware of the needs of the local community. Reception staff used digital flags within the care records system to highlight any specific individual needs, such as the requirement for longer appointments or for a translator to be present. Staff checked people’s health, care, and wellbeing needs during health reviews. Clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing. Our clinical searches demonstrated the provider had effective systems to identify people with previously undiagnosed conditions. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber. We found examples whereby referrals from staff to the Local Authority had resulted in support for people with disabilities at their home.

The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. However, there were gaps in how they managed some people with medicines optimisation and Infection Control.

Systems were in place to ensure staff were up to date with evidence-based guidance and legislation. However, not all clinical records we saw demonstrated care was provided in line with current guidance. Staff we spoke with demonstrated how they kept up to date with standards through notifications, individual and group learning.

The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Staff had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support. The practice worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services. Staff told us that they were well supported and had access to a senior colleague or manager to discuss clinical concerns if the need arose. We saw examples of the GP Registrar (Trainee GP) discussing a concern with the lead GP and seeking advice. This showed appropriate clinical oversight was in place and that patient safety was supported through effective communication and collaborative decision-making

The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduce their future needs for care and support.

Staff focussed on identifying risks to patients’ health, including those in the last 12 months of their lives, patients at risk of developing a long-term condition and those with caring responsibilities. Staff supported national priorities and initiatives to improve population health, including stopping smoking and tackling obesity. Staff could refer patients to a social prescriber who signposted to further sources of help and support. The practice also had literature in the waiting areas to inform patients of local and national support. However, literature was not always available in different languages. The provider told us that they were available in reception upon request.

The service did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

National data showed that the practice was not meeting the required targets for cervical screening and immunisations. We found that the percentage of children aged 5 who had received immunisation for measles, mumps and rubella (two doses of MMR) was at 80% whilst the national target was 95%. They were within range of other immunisation targets.

Cervical screening uptake was below national averages across both eligible age groups. Among women aged 50–64 years, 74% had received an adequate screening test within the previous 5.5 years, compared with the national target of 80%. Similarly, among women aged 25–49 years, only 65% had received an adequate screening test within the previous 3.5 years, compared with the national target of 80%. These results indicate that a significant proportion of eligible women were not participating in the cervical screening programme, increasing the risk that pre-cancerous changes and cervical cancer may not be identified and treated at an early stage, potentially leading to poorer health outcomes. The provider told us that they had a highly transient population who often did not understand the need for immunisations or screening,

The practice offered set appointments for immunisations and cervical screening but were also flexible to meet the needs of their population, they were able to do this through offering extended access appointments. The practice had a quality improvement programme involving clinical and non-clinical audits, this helped deliver effective care and support staff with additional learning needs. A clinical audit had recognised that some care notes were not comprehensive, however the provider did not ensure that these omissions were noted in the reviews.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff understood and applied legislation relating to consent. Capacity and consent were clearly recorded. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation. All staff were chaperone trained and knew how to support clinicians with examinations requiring chaperones.