Henmore Health - Brailsford Surgery

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 assessment for this service since its registration with CQC. This key question has been rated as Good.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There were processes in place for staff to report incidents, near misses and safety events and staff we spoke with were aware how to do this. Our review of significant events showed that lessons were learnt. Minutes from clinical and quality meetings showed significant events were discussed with clinical staff that attended these meetings. Trends in significant events had been assessed. A representative from the Patient Participation Group (PPG) felt the practice took concerns seriously and proactively made improvements to the service. However, one person told us how they had raised a significant event about their personal safety within the practice and it took 6 months before it was dealt with.

There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Learning from complaints resulted in changes that improved care for others. An annual audit of complaints had been carried out by the provider to identify trends in complaints.

Staff feedback was mixed when we asked if learning from significant events and complaints was shared with them. Clinical staff were mostly positive that learning was shared with them however, some non-clinical told us learning had not been shared with them.

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. Regular multi-disciplinary meetings were held to maintain a list of people at high risk of hospital admission and to expedite the discharge of patients with long-term conditions or people with frailty by providing care closer to or at home.

There were systems in place for processing information relating to new patients. The service worked with other providers to deliver shared care, for example the palliative care team. Referrals, pathology results and documents were managed in a timely manner. We reviewed a sample of 2 week wait referrals for potential cancer and found they had all been completed within 48 hours, many on the same day.

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 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 an up to date list of vulnerable people and acted on concerns working in partnership with other organisations.

The service worked with the larger multi-disciplinary team to share information and concerns. For example, health visitors and the community support team. Safeguarding meetings were used to raise awareness of potentially vulnerable groups of people. The service had systems in place to generate and corroborate the children’s safeguarding list with health visiting services and relevant cases were discussed at these meetings. There were systems in place to follow up people who failed to attend appointments in primary and secondary care or were frequent attenders to the emergency department.

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.

All of the recommended emergency equipment and medicines were available within the practice and maintained. A new system of completing records to demonstrate that emergency equipment and medicines were regularly checked had been put in place. Staff could recognise a deteriorating patient and knew of the action to take. People were advised on risks related to their condition and the actions to take if their condition deteriorated.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Health and safety risk assessments and audits had been undertaken and risks identified had been addressed or were under review.

A fire risk assessment had been completed, and staff completed online fire training and attended regular fire drills. However, records relating to the most recent fire drill, including details of who attended and how the procedure was executed, was not available. Action taken following the fire drill was recorded. The service had recently appointed new fire marshals who had yet to complete training specific to this role.

A legionella risk assessment had been completed and required action, as outlined in the action plans, had been completed. Regular testing of water temperatures took place. Electrical and medical equipment had been tested and calibrated as required. There was a business continuity plan in place which was monitored and reviewed.

The service mostly 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. Some staff expressed concerns regarding staffing levels, particularly staffing levels within the medical secretary, dispensary and nursing teams but acknowledged that 3 salaried GPs had recently been employed and there were adverts out to recruit a new practice nurse and dispenser.

There was a range of clinical and non-clinical roles within the practice. We found training was mostly up to date and learning needs and development of staff was in place. Staff gave examples of how they had been supported to develop and take on new roles. For example, a health care assistant had been supported to train as a nurse associate, a practice nurse was being supported to complete their training to become an advanced nurse practitioner and a clinical member of the team had been developed to take on the role of the quality and improvement lead. Competency checks for dispensing staff had been completed. Most staff received regular appraisals although 1 member of staff told us that after working in the practice for several years they had received their 1st appraisal after the announcement of this assessment.

Safe recruitment practices were followed.

However, systems to support non-medical prescribers were not accomplished. The provider told us they carried out regular audits of the prescribing of non-medical staff. We reviewed the audits and found the audits lacked any detail of what had been audited, only 1 consultation per non-medical prescriber had been completed and there was minimal learning or positive feedback identified. A non-medical prescriber we spoke with was not aware of the audits and had not received clinical supervision to discuss them. The provider showed us a team’s online chat where information regarding prescribing was provided to staff. We reviewed the chat and found that no information had been shared since 12 November 2024.

The provider showed us general clinical supervision forms for nursing staff. The most recent was dated 14 February 2024. Notes lacked detail. For example, it stated there had been a review of cases with the nursing team. However, there were no details about what was reviewed or what learning had been identified.

The service 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 was visibly clean and tidy on the day of our assessment although carpet in areas where patients did not have access to were heavily stained. Leaders told us they were steamed cleaned on a regular basis but were unable to provide documented evidence to support this.

The practice’s designated infection, prevention and control (IPC) lead had left the practice and staff were confused who the replacement IPC lead was. A member of staff told us that there was an advert to recruit a new practice nurse and they would be the lead once recruited. The IPC nurse from the provider’s other practice provided oversight in the interim. Staff had received appropriate IPC training. Cleaning schedules were in place and followed.

An IPC audit had been completed on 8 July 2024. Several areas of concern were identified and we found most of them had been addressed although it had not identified that clinical sinks had overflows which could harbor bacteria. The provider told us this was on their risk register and would be addressed when the new practice was built. The provider told us a repeat IPC audit was planned for 24 July 2025.

Staff vaccination was maintained in line with current UK Health and Security Agency (UKHSA) guidance if relevant to their role. The provider had updated the health declaration form completed by new staff to include information about immunisation status.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened. A representative from a care home where the service provided care and treatment told us that repeat prescriptions were dealt with in a timely manner and the service provided a delivery service to the home.

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. Staff had the appropriate authorisations to administer medicines.

Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. Prescribing data reviewed as part of our assessment confirmed this. For example, the overall volume of antibiotics prescribed by the practice was significantly lower than local and national averages.

There were suitable processes for staff to follow when dispensing medicines. The dispensary closed at 5pm despite the practice closure time of 6.30pm. A risk assessment to mitigate potential risks had been completed.

Staff followed protocols to ensure they prescribed medicines safely, and ensured people received all the recommended medicine reviews and monitoring. Medicines including controlled drugs were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines, vaccines, and controlled drugs. Staff stored medical gases, such as oxygen, safely. A system to identify stock that would imminently be out of date in the dispensary had not been followed and we found 2 bottles of medicine that people had returned, stored in the fridge with the person’s name removed. These should have been disposed of. Following our assessment the provider told us the whole stock had been rechecked to ensure there were not further issues and retraining on medicine disposal had been provided. They told us the incident was being investigated as a significant event and learning would be shared with staff.

There was a system in place for tracking prescription stationery throughout the practice. We found that this had not been effective, due to human error, and staff had not always followed the protocol in place. Following our assessment, the provider told us that retraining on their policy for tracking prescription stationary had been delivered to staff and the incident was being investigated as a significant event. Learning would be shared with staff.

The provider mostly had effective systems to manage and respond to Medicines and Healthcare products Regulatory Agency (MHRA) alerts and medicine recalls. Appropriate action had been put in place for people prescribed a medicine used in the treatment of diabetes. In one record we reviewed it was not clearly recorded that the person had been made aware of potential risks of a medicine that could cause defects in a developing foetus. Safety netting was in place though as this medicine could not be issued as a repeat. Staff followed established processes to ensure people prescribed medicines with specific risks received the recommended monitoring.