Updated 23 April 2025
Date of Assessment: 21 to 24 July 2025.
Henmore Health - Brailsford is a GP practice and delivers services to 5,787 patients under a contract held with NHS England. We carried out an assessment of this practice because it has not been assessed since it registered with the CQC in December 2023 and due to new emerging risks. The National General Practice Profiles states that the ethnic make-up of the practice area is 96.3% white, 1.1% mixed, 1.7% Asian, 0.6% black and other 0.3%. The age distribution of the practice shows a higher than average older population and lower than average younger population. Information published by the Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the 9th decile (9 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.
The service had an established learning culture and people could raise concerns. Managers investigated incidents thoroughly although not always in a timely manner. The provider had applied learning from our recent assessment of their other practice and carried out an analysis of their complaints to identify trends. People were protected and kept safe. Staff understood and managed risks. The facilities and equipment met the needs of people, were clean and well-maintained and any risks mitigated. The practice had recently recruited 3 salaried GPs and were in the process of recruiting other staff to ensure there were enough staff with the right skills, qualifications and experience. Managers made sure staff received training and regular appraisals to maintain high-quality care. However, clinical supervision and auditing of the prescribing of non-medical prescribers needed to be improved. Staff managed medicines well and involved people in planning any changes.
People were involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. Care was based on latest evidence and good practice. Staff worked with agencies involved in people’s care for the best outcomes and smooth transitions when moving services. Staff made sure people understood their care and treatment to enable them to give informed consent. Staff involved those important to people to make decisions in people’s best interests where they did not have capacity.
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. Not all staff felt their wellbeing needs were considered or met.
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 easy to access and worked to eliminate discrimination. People received fair and equal care and treatment. The service worked to reduce health and care inequalities through training and feedback. People were involved in planning their care and understood options around choosing to withdraw or not receive care.
Leaders had shared their vision and mission statement with staff. However, most staff told us they had not been involved in developing the vision. Leaders were not visible and did not visit the practice on a regular basis. Some staff told us that leaders were not compassionate or understanding of their needs. Some staff felt supported to give feedback and were treated equally. Other staff did not feel supported and feared repercussions if they shared concerns with the CQC. Staff understood their roles and responsibilities. There were systems in place to drive learning and innovation within the practice.
We a found breach of regulation in relation to good governance. We have asked the provider for an action plan in response to the concerns found at this assessment.