River Brook Medical Centre

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 requires improvement.

We identified a breach of Regulation 12 (Safe care and treatment) because the provider did not have training for Infection Control for all staff including additional training for the Infection Control lead and did not optimise how they use medicines. They also did not have good access to emergency equipment or emergency drugs.

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 complete honesty. They actively listened to concerns about safety and thoroughly investigated and reported safety events. Lessons were always learnt to continually identify and embed good practice.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. Representatives from the Patient Participation Group (PPG) felt the provider took concerns seriously and proactively made improvements to the service. Managers encouraged staff to raise concerns when things went wrong. During staff meetings, the whole team discussed and learnt from events. Staff felt there was an open culture, and that safety was a top priority. The provider had processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Learning from incidents and complaints resulted in changes that improved care for others. When concerns were identified, they acted quickly to manage risk.

There were 3 significant events recorded in the previous 12 months, and the provider had systems in place to review these as part of an annual significant event analysis (SEA) review. They used comprehensive analysis to recognise trends or themes. Those we sampled had been reviewed, analysed and shared in line with policy. Significant events were discussed with staff to enable actions to improve patient safety, quality of care, and operational effectiveness. We saw that when an error had been made in blood tests, the provider discussed the concern within the clinical group as well as the person to minimise risk of reoccurrence. Staff were offered time to reflect and consider additional learning.

There was a system to record and investigate complaints. Information reviewed demonstrated that people had opportunities to provide feedback, and they knew how to make a complaint. Lessons were learnt from individual complaints and shared with the practice team to improve the quality of care. Feedback and information was available in the practice and on their website.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

There were systems in place for processing information relating to new registrations. We found systems were in place to ensure referrals and test results were managed in a timely way.

We saw that people who had received care in hospital had follow up appointments and medicines reviews where necessary. There was a range of structured meetings in place including full team, clinical and management meetings. These were used to support safe systems by facilitating information sharing, discussion and oversight of safeguarding, palliative care, clinical and operational matters.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Safeguarding policies were in place and understood by staff, all of whom were appropriately trained in safeguarding procedures. Staff had access to a designated safeguarding lead for adults and children. The practice maintained a register of vulnerable individuals, and we saw registers were routinely reviewed and relevant information was shared effectively within the team. Staff responded proactively to concerns, implementing actions and learning in collaboration with partner organisations during multi-disciplinary team meetings.

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

People told us that they received support and advice regarding how to manage their conditions. For example, a person with stress related health concerns had been assessed for a possible referral to specialist care and was happy with the outcome.

Staff could recognise a deteriorating patient and knew of action to take. They were trained in sepsis awareness, anaphylaxis, cardiopulmonary resuscitation (CPR), and basic life support. People were advised on risks related to their condition and actions to take if their condition deteriorated.

Reception and administrative staff were aware of potential red flag symptoms and could undertake basic triage of telephone calls from patients. They knew when to notify a GP or other clinicians with concerns about a patient who may be acutely unwell and/or deteriorating. Staff had been provided with training in health and safety related topics such as fire safety, basic life support and resuscitation.

Not all the recommended emergency medicine were readily available with no risk assessment to explain the decision making and access to emergency equipment was restricted due to the type of tags used to secure the bags. The provider made changes which included cutting off the tags and obtaining the emergency medicines required.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Contracts were in place to ensure the premises were maintained. Health and safety risk assessments and audits had been undertaken. The premises were clean and in good condition. There was a business continuity plan in place which was monitored and reviewed.

However, we found that 2 pedal waste bins for non-clinical waste did not have working lids. The provider assured us that they would order news bins immediately.

The service did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual

Training records demonstrated that most mandatory and role-specific training was up to date. However, the provider was in the process of transferring training records from one system to another and clear oversight had not been maintained. The provider could not be assured that all staff had completed all the required training in a timely manner. Learning and development needs were generally managed appropriately However, we found that staff had not received an annual appraisal with the most recent occurring in 2024. Regular appraisals are important to support professional development, review performance, and identify any learning or training needs. Following our assessment, the provider advised that all outstanding staff appraisals and training would be completed within the next three months.

The provider was not completing comprehensive supervision with staff on a regular basis. Supervision can be used for staff to identify concerns and ask for additional support whilst provider can check quality of work and address any concerns.

Staff were recruited safely and all mandatory checks were made including a valid recent Disclosure and Barring Service (DBS) certificate and referencing. Temporary staff had staff files which included all mandatory training and checks.

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly. We also found that the provider had not ensured there was a suitably trained IPC lead in post. Although an IPC lead had been identified within the IPC policy, they had not completed the appropriate training required to effectively undertake the role. In addition, not all staff had completed the level of IPC training appropriate to their role. We found that some administrative staff were not IPC trained. This meant the provider could not be assured that staff had the necessary knowledge and skills to consistently follow current IPC guidance, identify and respond to infection risks, safely manage contaminated equipment and materials, and minimise the risk of cross-contamination.

Despite these gaps, during our site visit the premises were visibly clean, tidy and well maintained. The provider reported that no IPC incidents or concerns had been identified and the ICB had completed an IPC visit with no concerns identified. Staff were able to describe infection prevention and control procedures and demonstrate an understanding of how to identify and respond to risks. However, the lack of appropriate IPC training and leadership reduced assurance that safe IPC practices would be consistently maintained.

Cleaning materials, chemicals and contaminated spill kits were stored appropriately, and staff demonstrated an understanding of how to respond to contamination incidents. Staff had access to occupational health support, including immunisations to reduce the risk of exposure to blood-borne viruses and other infectious diseases.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

Staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely. People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms. Staff received regular training, were competency assessed on medicines optimisation, and felt confident managing the storage, administration and recording of medicines.

As part of our assessment, remote clinical searches were conducted by our GP Specialist Advisor. Clinical records were not clear and did not always provide details of the appointment and diagnoses.

Clinical searches undertaken by the GP Specialist Advisor identified concerns regarding the monitoring of people prescribed ACE inhibitors. Out of 93 people who were on these medicines, we reviewed five peoples records and found that all five had not received an appropriate review within the required timeframe.

ACE inhibitors are associated with recognised risks, including deterioration of kidney function. Without regular monitoring and review, these adverse effects may not be identified promptly, potentially impacting an individual's health outcomes. Failure to undertake timely medication reviews also increases the risk that treatment may continue despite changes in a person's clinical condition or the emergence of contraindications.

Our GP SpA also found 4 examples of 51 records where people were prescribed medicines associated with an increased risk of gastrointestinal complications but had not been prescribed proton pump inhibitor (PPI) gastroprotection. Clinical records did not clearly document the rationale for this decision; however people were not harmed and decisions had been discussed with senior GPs. PPIs are commonly prescribed to reduce the risk of gastrointestinal irritation, ulceration and bleeding in patients receiving certain medicines, particularly where recognised risk factors are present.

The provider has told us that they immediately contacted all people concerned and made arrangements for a review. All medical records have been reviewed and include updates.

The emergency medicines and equipment bag had seals that could not easily opened without scissors, which meant that it would take more staff to address an emergency increasing risk. Naloxone (a drug used to inhibit the effects of a drug overdose) was not available within the practice which increased risk to people who may have overdosed on narcotic substances.

Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments. The provider had effective systems to manage and respond to safety alerts and medicine recalls.

Prescription stationery was appropriately stored and controlled drugs were secure and there was a programme of regular clinical audits of prescribing that focused on improving care and treatment, however we found gaps in medication records.