River Brook Medical Centre

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.

We identified a breach of Regulation 17 (Good Governance) because the provider's systems and processes for assessing, monitoring and improving the quality and safety of services were not sufficiently effective. Several risks had not been identified through routine audits, reviews or oversight processes.

This service scored 61 (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.

All staff had contributed to the development of the practice vision and strategy, which was kept under review. We saw that staff meetings involved discussing future plans and actively seeking comments from staff. We saw an examples where the provider listened to staff and acted upon suggestions made such as increasing uptake of childhood immunisation.

The practice was aware of the projected increase in the local population and was working with partner agencies to address future challenges. The provider told us they took a collaborative approach, engaging with staff to ensure there was a shared understanding of the service’s vision and objectives.

Although leaders demonstrated some of the skills and experience required to lead effectively, we identified gaps in governance arrangements which limited their ability to identify and address issues in a timely way. However, leaders were open and responsive to feedback, demonstrated a commitment to improvement, and took prompt action to address issues identified during the inspection.

Staff understood the values of putting people first, treating them with dignity, and working together to provide safe and compassionate care. Leaders made sure these values were part of everyday practice and reflected in the delivery of the service. The culture was open and respectful.

Staff described feeling valued and motivated in their roles, with leaders who listened and recognised their contributions. Staff told us they felt included and supported. They said managers were approachable and encouraged them to share ideas or raise concerns.

Regular meetings gave staff time to reflect on their work, learn from each other, and stay focused on what mattered most to the people they supported. We saw the leadership team worked with other practices in the primary care network and were engaged in the development of primary care services within the local area.

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

The Freedom to Speak Up Guardian (FTSU) was independent of the service. Staff were able to tell us what the FTSUG position meant to them and how they could contact them.

We saw that staff meetings were taking place regularly, with staff able to discuss concerns, a group setting or one to one with the management team.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Policies and procedures to promote diversity and equality were in place. Adjustments had been made to ensure all staff were valued, and the wellbeing of staff was supported.

The service promoted a culture of equality, diversity, and inclusion. Leaders ensured staff were recruited fairly and valued for their skills, knowledge, and personal qualities, regardless of background or personal circumstances. Staff told us they felt respected and treated fairly.

Training in equality and diversity was provided, and staff understood the importance of creating an inclusive environment both within the workplace and in the care they delivered. Staff said the service encouraged openness and respected individual differences, which helped build a positive and supportive team culture.

The service did not always have clear responsibilities, roles, systems of accountability and good governance. They did not always act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

Governance systems were not always effective in identifying and mitigating risks. Infection prevention and control (IPC) audits had not identified that some administrative staff had not completed required IPC training, that there was no appropriately trained IPC lead in post, and that the provider was not following its own IPC policy, increasing the risk of inconsistent IPC practices and preventable infection transmission. Environmental audits had failed to identify damaged blinds in clinical areas, creating a risk that people’s privacy and dignity could be compromised during consultations and examinations. Audits had also not identified that bins in a public toilet and reception area did not have closing lids, increasing the risk of infection spread, or that nearly 50% of people were finding it difficult to contact the surgery by telephone. Effective governance processes should have identified that immunisations and cervical screening systems had not been effective.

Emergency medicines and equipment were in place, however, we found systems for checking emergency medicines and equipment had failed to identify that security seals on emergency medicines required a cutting tool to access them, which could result in delays during a medical emergency. Medicines governance arrangements had not identified that naloxone was unavailable within the practice and that no documented risk assessment had been completed to justify its absence or demonstrate how associated risks had been mitigated, potentially affecting the practice’s ability to respond effectively to opioid-related emergencies.

In addition, the provider did not have effective systems to review people’s clinical records and monitoring of some medicines. Clinical audit processes had not identified shortcomings in clinical record keeping. We reviewed five patient records and found that information was not always recorded in line with guidance with records lacking clear treatment plans and the rationale for clinical decisions increasing the risk of poor continuity of care and reducing assurance that clinical decisions were appropriately made and monitored. Not all staff received annual appraisals which was not in line with the providers own policy. Appraisals help staff and managers to understand staff needs in training or support and allow staff to determine focus areas for the following year. Infection Control training had not been completed for all staff and the Infection Control Lead did not have the additional appropriate training required.

However, the provider was responsive when we bought these concerns to them during the inspection and immediately made changes to ensure people were kept safe. For example, they implemented further training where required and naloxone was bought to supplement the emergency medicines kit.

Leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Staff could access all required policies and procedures. Managers held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks. Managers clearly recorded any actions arising from these meetings and ensured they shared these with staff. Staff took patient confidentiality and information security seriously.

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

The provider worked with other practices within their primary care network to offer extended access, and flu and covid vaccination programmes.

The provider utilised the Patient Participation Group (PPG) to reach out to all patients and people within the community to increase take-up of vaccinations and screening. People fed back that they felt valued by the practice and listened to. Feedback from people demonstrated they felt listened to and valued by the practice, supporting effective engagement with the local community.

The service did not always focus upon continuous learning, innovation and improvement across the organisation and local system.

They encouraged creative ways of delivering equality of experience, outcome and quality of life for people by speaking to them in their own languages and understanding cultural differences

However, overall quality system was not sufficiently effective in identifying risks or ensuring that learning was captured and used to drive sustained improvement in areas such as IPC, medication reviews, access and screening.