Brownsover 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 good.

This service scored 72 (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 honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. Managers encouraged staff to raise concerns when things went wrong. During staff meetings, the whole team discussed and learnt from clinical issues. 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. The provider managed several GP practices and learning could be shared between them to promote improvements.

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.

The service worked with other providers to deliver shared care and when patients moved between services. Referrals and test results were managed in a timely way. The provider had an effective system in place to ensure that all pathology results are actioned within 24 hours.

Whilst we found a high number of medical notes waiting to be summarised the provider was aware and had a risk assessment in place prioritising the records of vulnerable patients with a plan to complete the remaining backlog by July 2027.

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 known to staff, who were appropriately trained in safeguarding procedures. The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations. Safeguarding meetings were conducted regularly with external agencies, and we found evidence of actions taken. Digital alerts were visible on the clinical system so staff could manage people appropriately. We found family members of children with safeguarding alerts were linked to the child’s records and had corresponding clinical alerts in place.

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

Emergency equipment was available and maintained. Staff could recognise a deteriorating patient and knew of action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated. The practice had developed a triage sheet to support reception staff to navigate patients effectively to the right clinician or emergency services.

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 and risks identified had been addressed. Whilst the building was dated, the practice took necessary actions to keep the premises safe to deliver effective care. There was a business continuity plan in place which was monitored and reviewed.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

There were a range of clinical and non-clinical roles within the practice. We found training was up to date, learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence. Safe recruitment practices were followed. We found that the practice had an effective system of supervision evidencing discussions and learning outcomes to ensure safe practice and development of staff. Staff told us that there was an open-door policy, and we found evidence of clinical discussions to support in patient records. GPs also had daily clinical huddles with all Spirit locations to share cases and gain support. The nurses were involved in annual clinical audits in which consultation notes were assessed and learning shared. The provider had also adopted a competency matrix which was conducted annually to identify any learning needs or policy review staff may need to support continued effective care of patients.

The service overall assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The practice had a designated infection, prevention and control lead and all staff had completed relevant training. Cleaning schedules were in place and followed. Risk assessments and audits were completed. During the onsite inspection we found clinical rooms had non wipeable chairs, the provider acknowledged the potential risk and began making arrangements to replace all clinical chairs to comply with IPC standards.

The service did not always make sure that medicines and treatments were safe and met people’s needs and preferences.

As part of our assessment, remote clinical searches were conducted by a GP Specialist Advisor. During the clinical searches, we found that not all systems and processes worked effectively as not all medication reviews and monitoring were completed in line with best practice. We reviewed a selection of patient clinical records and saw instances where staff had prescribed high risk medicines to patients without the required monitoring tests and reviews being undertaken. Following our feedback the provider took immediate action and provided evidence to show these patients were followed up for monitoring The provider also discussed findings with the clinical team and put systems in place to identify patients needing a review.

Staff received regular training and felt confident managing the storage, administration, and recording of medicines. People knew what to do and who to contact if their condition did not improve or if they experienced any unexpected symptoms. Prescription stationery was managed appropriately and stored securely.

Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines. Waste medicines were recorded and disposed of appropriately including medicines returned by patients. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments.

The provider had effective systems to monitor and review emergency medicines and equipment.