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Inspection Summary


Overall summary & rating

Good

Updated 7 November 2019

We carried out an announced comprehensive inspection at The Brook Surgery Limited on 05 September 2019 as part of our ratings inspection programme for Independent Health Providers.

The service has two registered managers, both of whom are doctors at the service. A registered manager is a person who is registered with the CQC to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting

the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The Brook Surgery is a private doctor service based in the Golders Green area of North London. The service offers GP appointments, home visits, healthcare management, child vaccinations, travel vaccine clinic, flu vaccine clinic, well woman clinic, cryotherapy, healthcare screening and a private dispensary.

We received 36 completed care Quality Commission (CQC) comment cards, all of which were positive. Patients described the service as excellent, and referred to professional and efficient staff who were consistently attentive, friendly and considerate. There were no negative comments.

Our key findings were

:

  • There were systems in place to safeguard children and vulnerable adults from abuse and staff we spoke with knew how to identify and report safeguarding concerns. All staff had been trained to a level appropriate to their role.
  • The service had systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the service learned from them and improved their processes.
  • The service carried out staff checks on recruitment, including checks of professional registration where relevant.
  • Clinical staff we spoke with were aware of current evidence-based guidance and they had the skills, knowledge and experience to carry out their roles.
  • There was evidence of quality improvement, including clinical audit.
  • Consent procedures were in place and these were in line with legal requirements.
  • Systems were in place to protect personal information about patients. The service was registered with the Information Commissioner’s Office (ICO).
  • Patients were able to access care and treatment from the clinic within an appropriate timescale for their needs.
  • Information about services, fees and membership options as well as the complaints process were available in the waiting area and online.
  • The service had proactively gathered feedback from patients.
  • Governance arrangements were in place. There were clear responsibilities, roles and systems of accountability to support good governance and management.

The areas where the provider should make improvements are:

  • Review systems used to manage personnel records to ensure managers can be assured all required checks are in place and required mandatory training is up to date.

Dr Rosie Benneyworth BM BS BMedSci MRCGP


Chief Inspector of Primary Medical Services and Integrated Care

Inspection areas

Safe

Good

Updated 7 November 2019

There were systems for reporting, recording and learning from significant events and the service had a range of risk assessments and action plans to minimise risks to staff and patients.

There were adequate arrangements to respond to emergencies and major incidents. Staff checks were undertaken at the time of recruitment although we found improvements could be made to the way the provider kept records of these checks.

Safety systems and processes

The service

had

clear systems to keep people safe and safeguarded from abuse.

  • The provider conducted safety risk assessments. It had appropriate safety policies, which were regularly reviewed and communicated to staff including locums. They outlined clearly who to go to for further guidance. Staff received safety information from the service as part of their induction and refresher training. The service had systems to safeguard children and vulnerable adults from abuse.
  • The service had systems in place to assure that an adult accompanying a child had parental authority to give consent to care or treatment.
  • The service worked with other agencies to support patients and protect them from neglect and abuse. Staff took steps to protect patients from abuse, neglect, harassment, discrimination and breaches of their dignity and respect.
  • The provider carried out staff checks at the time of recruitment and on an ongoing basis where appropriate, although systems in place to maintain personnel files were used inconsistently. For instance, when we looked at the personnel file for one clinician, there was no information to show references had been received or a Disclosure and Barring Service (DBS) check had been undertaken. The service was able to provide this information after locating documents stored in different records. Before the inspection finished, we saw that DBS checks had been undertaken for all staff where this was required. DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable.

  • All staff received up-to-date safeguarding and safety training appropriate to their role. They knew how to identify and report concerns. Staff who acted as chaperones were trained for the role and had received a DBS check.
  • There was an effective system to manage infection prevention and control. The provider had undertaken a legionella risk assessment within the previous twelve months.
  • The provider ensured that facilities and equipment were safe and that equipment was maintained according to manufacturers’ instructions. There were systems for safely managing healthcare waste.
  • The provider carried out appropriate environmental risk assessments, which took into account the profile of people using the service and those who may be accompanying them.

Risks to patients

There

were systems to assess, monitor and manage risks to patient safety.

  • There were arrangements for planning and monitoring the number and mix of staff needed.
  • There was an effective induction system for agency staff tailored to their role.
  • Staff understood their responsibilities to manage emergencies and to recognise those in need of urgent medical attention. They knew how to identify and manage patients with severe infections, for example sepsis and all consulting rooms contained appropriate equipment to enable assessment of patients with presumed sepsis.
  • There were suitable medicines and equipment to deal with medical emergencies which were stored appropriately and checked regularly, although we noted the oxygen tank was just under half full at the time of our inspection. The provider placed an order for a replacement tank before the inspection finished. If items recommended in national guidance were not kept, there was an appropriate risk assessment to inform this decision.
  • When there were changes to services or staff the service assessed and monitored the impact on safety.
  • There were appropriate indemnity arrangements in place.

Information to deliver safe care and treatment

Staff

had

the information they needed to deliver safe care and treatment to patients.

  • Individual care records were written and managed in a way that kept patients safe. The care records we saw showed that information needed to deliver safe care and treatment was available to relevant staff in an accessible way.
  • The service had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment.
  • The service had a system in place to retain medical records in line with Department of Health and Social Care (DHSC) guidance in the event that they cease trading.
  • Clinicians made appropriate and timely referrals in line with protocols and up to date evidence-based guidance.

Safe and appropriate use of medicines

The service

had

reliable systems for appropriate and safe handling of medicines.

  • The systems and arrangements for managing medicines, including vaccines, controlled drugs, emergency medicines and equipment minimised risks. The service kept prescription stationery securely and monitored its use.
  • We saw evidence the service carried out medicines audits to ensure prescribing was in line with best practice guidelines for safe prescribing.
  • The service prescribed Schedule 2 and 3 controlled drugs (medicines that have the highest level of control due to their risk of misuse and dependence). The practice held stocks of controlled drugs (medicines that require extra checks and special storage arrangements because of their potential for misuse) and had in place standard procedures that set out how they were managed. These were being followed by the practice staff. For example, controlled drugs were stored in a controlled drugs cupboard, access to them was restricted, a record of the controlled drugs was maintained and the keys were held securely. There were arrangements in place for the destruction of controlled drugs. Members of dispensing staff were aware of how to raise concerns around controlled drugs with the controlled drugs accountable officer in their area.
  • Staff prescribed, administered or supplied medicines to patients and gave advice on medicines in line with legal requirements and current national guidance. Processes were in place for checking medicines and staff kept accurate records of medicines. Where there was a different approach taken from national guidance there was a clear rationale for this that protected patient safety.
  • There were effective protocols for verifying the identity of patients including children.

Track record on safety and incidents

The service

had

a good safety record.

  • There were comprehensive risk assessments in relation to safety issues.
  • The service monitored and reviewed activity. This helped it to understand risks and gave a clear, accurate and current picture that led to safety improvements.

Lessons learned and improvements made

The service learned and made improvements when things went wrong.

  • There was a system for recording and acting on significant events. Staff understood their duty to raise concerns and report incidents and near misses. Leaders and managers supported them when they did so.
  • There were adequate systems for reviewing and investigating when things went wrong. The service learned, and shared lessons, identified themes and took action to improve safety in the service. For instance, we saw details of an occasion when a patient was prescribed an incorrect medicine by a specialist provider because information included in a referral letter was not accurate. The service had contacted the patient, explained the error and apologised. The service had also contacted the specialist provider acknowledging the mistake and providing the correct information. To avoid a repeat occurrence, the matter had been discussed in a clinical meeting where a root cause analysis had been undertaken. As a result of the incident, the service had undertaken an audit of clinical notes but no further concerns were found.
  • The provider was aware of and complied with the requirements of the Duty of Candour and we saw examples of occasions when the provider had complied with this duty. The provider encouraged a culture of openness and honesty. The service had systems in place for knowing about notifiable safety incidents

When there were unexpected or unintended safety incidents:

  • The service gave affected people reasonable support, truthful information and a verbal and written apology.
  • They kept written records of verbal interactions as well as written correspondence.
  • The service acted on and learned from external safety events as well as patient and medicine safety alerts. We saw evidence showing the service had an effective mechanism in place to disseminate alerts to all members of the team including sessional and agency staff.

Effective

Good

Updated 7 November 2019

The provider had systems to keep clinicians up to date with current evidence-based practice. We saw evidence that clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance (relevant to their service).

Effective needs assessment, care and treatment

The provider had systems to keep clinicians up to date with current evidence-based practice. We saw evidence that clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance (relevant to their service)

  • We saw evidence the provider assessed needs and delivered care in line with relevant and current evidence-based guidance and standards such as the National Institute for Health and Care Excellence (NICE) best practice guidelines.
  • Patients’ immediate and ongoing needs were fully assessed. Where appropriate this included their clinical needs and their mental and physical wellbeing.
  • Clinicians had enough information to make or confirm a diagnosis.
  • We saw no evidence of discrimination when making care and treatment decisions.
  • Arrangements were in place to deal with repeat patients.
  • Staff assessed and managed patients’ pain where appropriate.

Monitoring care and treatment

The service was actively involved in quality improvement activity.

  • The service used information about care and treatment to make improvements.
  • The service made improvements through the use of completed audits. Clinical audit had a positive impact on quality of care and outcomes for patients. There was clear evidence of action to resolve concerns and improve quality. For instance, we saw the provider had undertaken three audit cycles of antibiotic prescribing over the previous three years. This had led to a small reduction in antibiotic prescribing, with the percentage of consultations involving a prescription for antibiotics reducing from 14% to 13.6%.

Effective staffing

Staff had the skills, knowledge and experience to carry out their roles.

  • All staff were appropriately qualified. All doctors were in The provider had an induction programme for all newly appointed staff.
  • All doctors were registered with the General Medical Council (GMC) and were up to date with revalidation. All doctors were also members of the Royal College of General Practitioners.
  • The provider understood the learning needs of staff and provided protected time and training to meet them. Up to date records of skills, qualifications and training were maintained. Staff were encouraged and given opportunities to develop.
  • Staff whose role included immunisation and reviews of patients with long term conditions had received specific training and could demonstrate how they stayed up to date.

Coordinating patient care and information sharing

Staff worked together, and worked well with other organisations, to deliver effective care and treatment.

  • Patients received coordinated and person-centred care. Staff referred to, and communicated effectively with, other services when appropriate. For examples, we saw the service had a safety netting process in place to ensure patients referred to other providers received and attended appointments
  • Before providing treatment, doctors at the service ensured they had adequate knowledge of the patient’s health, any relevant test results and their medicines history. We saw examples of patients being signposted to more suitable sources of treatment where this information was not available to ensure safe care and treatment.
  • All patients were asked for consent to share details of their consultation and any medicines prescribed with their registered GP on each occasion they used the service.
  • The provider had risk assessed the treatments they offered. They had identified medicines that were not suitable for prescribing if the patient did not give their consent to share information with their GP, or they were not registered with a GP. For example, medicines liable to abuse or misuse, and those for the treatment of long-term conditions such as asthma. Where patients agreed to share their information, we saw evidence of letters sent to their registered GP in line with GMC guidance and we saw instances where the service had worked with the patient’s GP practice to develop a shared care plan.
  • Patient information was shared appropriately (this included when patients moved to other professional services), and the information needed to plan and deliver care and treatment was available to relevant staff in a timely and accessible way. There were clear and effective arrangements for following up on people who had been referred to other services.

Supporting patients to live healthier lives

Staff were consistent and proactive in empowering patients, and supporting them to manage their own health and maximise their independence.

  • Where appropriate, staff gave people advice so they could self-care.
  • Risk factors were identified, highlighted to patients and where appropriate highlighted to their normal care provider for additional support. For instance, the service did not routinely provide ongoing medical care or treatment for patients with long-term conditions but would highlight results where these indicated additional support was required.
  • Where patients needs could not be met by the service, staff redirected them to the appropriate service for their needs.

Consent to care and treatment

The service obtained consent to care and treatment in line with legislation and guidance

.

  • Staff understood the requirements of legislation and guidance when considering consent and decision making.
  • Staff supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision.
  • The service monitored the process for seeking consent appropriately.

Caring

Good

Updated 7 November 2019

The Brook Surgery demonstrated that they ensured patients were involved in decisions about their treatment, that their needs were respected, and that services were provided in a way that was caring and supportive.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • The service sought feedback on the quality of clinical care patients received
  • Feedback from patients was positive about the way staff treat people
  • Staff understood patients’ personal, cultural, social and religious needs. They displayed an understanding and non-judgmental attitude to all patients.
  • The service gave patients timely support and information.

Involvement in decisions about care and treatment

Staff helped patients to be involved in decisions about care and treatment.

  • The provider told us how they would arrange interpretation services if a patient specifically requested this although we were also told that people using the service were generally aware English was the spoken language at the service and chose to use the service on that basis.
  • Patients told us through comment cards, that they felt listened to and supported by staff and had sufficient time during consultations to make an informed decision about the choice of treatment available to them. We received 36 completed cards, all of which were entirely positive.
  • For patients with learning disabilities or complex social needs family, carers or social workers were appropriately involved.
  • Staff communicated with people in a way that they could understand, for example, the provider was able to show us online resources they would use to aid communication when necessary, including easy read materials and video clips.

Privacy and Dignity

The service respected patients’ privacy and dignity.

  • Staff respected confidentiality at all times.
  • Staff understood the requirements of legislation and guidance when considering consent and decision making.
  • Staff supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision.
  • Staff knew that if patients wished to discuss sensitive issues or appeared distressed they could offer them a private room to discuss their needs.
  • The service monitored the process for seeking consent appropriately.

Responsive

Good

Updated 7 November 2019

The Brook Surgery ensured they responded to patients’ needs for treatment and that they were able to deliver those services.

Responding to and meeting people’s needs

The service organised and delivered services to meet patients’ needs.

It took account of patient needs and preferences.

  • The provider understood the needs of their patients and improved services in response to those needs. For instance, patients had a choice of seeing male or female doctors every day the service was open.
  • Appointments were structured in a way which meant patients could request routine appointments with their preferred doctor. We were told this was also often the case with urgent appointments.
  • The provider had made arrangements to provide out of hours GP services when the service was closed. Information about this service was available on the service website, although it was also made clear that patients should dial 999 in an emergency.
  • Patients who were unable or did not wish to visit the service in person could request a home visit. We were told GPs had carried out over 300 home visits in the previous twelve months.
  • The provider had an in-house dispensary which stocked a range of commonly used medicines, although we were told less common medicines could be ordered when requested. Patients had the option to have prescribed medicines dispensed by the service or by community pharmacists.
  • The facilities and premises were appropriate for the services delivered. The service was entirely on the ground floor and was fully accessible throughout.
  • Reasonable adjustments had been made so that people in vulnerable circumstances could access and use services on an equal basis to others.
  • The service hosted an independent psychotherapy service. Although this was not managed or overseen by the provider, it had sought assurances clinicians providing that service were qualified, appropriately registered and had received DBS checks.

Timely access to the service

Patients were able to access care and treatment from the service within an appropriate timescale for their needs.

  • We were told over half of all appointments were available to book on the same day.
  • Patients with the most urgent needs had their care and treatment prioritised.
  • The provider told us they had a policy of ensuring patients visiting the service with urgent needs were seen even when no appointments were available.
  • Patients had timely access to initial assessment, test results, diagnosis and treatment. The provider was aware many of its patients preferred to receive test results on the same or next day where this was possible and arrangements were in place to have pathology samples collected several times each day. This meant results were often available within hours of the test being undertaken
  • Waiting times, delays and cancellations were minimal and managed appropriately.
  • Referrals to other services were undertaken in a timely way. We saw records showing these were often completed during consultations.

Listening and learning from concerns and complaints

The service took complaints and concerns seriously and responded to them appropriately to improve the quality of care.

  • Information about how to make a complaint or raise concerns was available. Staff treated patients who made complaints compassionately.
  • The service informed patients of any further action that may be available to them should they not be satisfied with the response to their complaint.
  • The service had complaint policy and procedures in place. Although the service had not received any complaints since the previous inspection, we saw there were processes in place to ensure lessons were from individual concerns.

Well-led

Good

Updated 7 November 2019

The Brook Surgery provided services which were well led and well organised, within a culture that was keen to promote high quality care in keeping with their systems and procedures. However, we found improvements could be made to systems in place to manage recruitment and personnel records.

Leadership capacity and capability;

Leaders had the capacity and skills to deliver high-quality, sustainable care.

  • Leaders were knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges and were addressing them. For instance, the provider was investing in improved IT systems to ensure the clinical record system continued to be compliant with information governance requirements.
  • Leaders at all levels were visible and approachable. They worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership. Staff we spoke with told us the management team were keen to hear their views and would incorporate viable suggestions to improve the service into the business plan.
  • The provider had effective processes to develop leadership capacity and skills, including planning for the future leadership of the service. For instance, the service had started to develop a succession plan to ensure any changes to the leadership team were managed and would not impact on safety, effectiveness or patient satisfaction.

Vision and strategy

The service had a clear vision and credible strategy to deliver high quality care

and promote good outcomes for patients.

  • There was a clear vision and set of values and these were articulated in the provider’s mission statement. The service had a realistic strategy and supporting business plans to achieve priorities.
  • The service had made a strategic decision to model services on a traditional family practice, providing continuity of care throughout patient’s lives and it had a clear view on the importance this had in patient safety and outcomes.
  • The service developed its vision, values and strategy jointly with staff.
  • Staff were aware of and understood the vision, values and strategy and their role in achieving them.
  • The service monitored progress against delivery of the strategy.

Culture

The service had a culture of high-quality sustainable care.

  • Staff felt respected, supported and valued. They were proud to work for the service.
  • The service focused on the needs of patients.
  • Leaders and managers acted on behaviour and performance inconsistent with the vision and values.
  • Openness, honesty and transparency were demonstrated when responding to incidents and complaints. For instance, we noted that when the service became aware of a safety alert relating to a non-branded medicine available from the dispensary, it contacted patients who had bought this item, informed them about the alert and advised patients to use an alternative brand until the alert was rescinded. We also noted the provider had communicated with the distributer of the medicine as part of their own investigation into the alert.

  • The provider was aware of and had systems to ensure compliance with the requirements of the duty of candour and we saw an example of when it had demonstrated this.

  • Staff told us they could raise concerns and were encouraged to do so. They had confidence that these would be addressed.
  • There were processes for providing all staff with the development they need. This included appraisal and career development conversations. All staff who were eligible for an annual appraisal in the last year had received one. Staff were supported to meet the requirements of professional revalidation where necessary. All clinical staff were considered valued members of the team.
  • There was a strong emphasis on the safety and well-being of all staff. We saw an example of a specific occasion when the service had provided significant emotional support to staff, including one to one counselling to any staff member who requested it.
  • The service actively promoted equality and diversity.
  • There were positive relationships between staff and teams.

Governance arrangements

There were responsibilities, roles and systems of accountability to support good governance and management.

  • Structures, processes and systems to support good governance and management were clearly set out, understood and effective. The governance and management of partnerships, joint working arrangements and shared services promoted interactive and co-ordinated person-centred care.
  • Staff were clear on their roles and accountabilities.
  • Leaders had established proper policies, procedures and activities to ensure safety and assured themselves that they were operating as intended. However, we found recruitment and personnel files were not managed consistently. For instance, when we asked to see details of DBS checks, professional registrations and mandatory training, the provider needed to consult several different sources, including emails, paper records and electronic files, to collate the information.

Managing risks, issues and performance

There were clear and effective processes for managing risks, issues and performance.

  • There was an effective, process to identify, understand, monitor and address current and future risks including risks to patient safety.
  • The service had processes to manage current and future performance. Performance of clinical staff could be demonstrated through audit of their consultations, prescribing and referral decisions. Leaders had oversight of safety alerts, incidents, and complaints.
  • Clinical audit had a positive impact on quality of care and outcomes for patients. There was clear evidence of action to change services to improve quality.
  • The provider had plans in place and had trained staff for major incidents.

Appropriate and accurate information

The service acted on appropriate and accurate information.

  • Quality and operational information was used to ensure and improve performance.
  • Quality and sustainability were discussed in relevant meetings where all staff had sufficient access to information.
  • The service used performance information which was reported and monitored and management and staff were held to account
  • The information used to monitor performance and the delivery of quality care was accurate and useful. There were plans to address any identified weaknesses.
  • The service submitted data or notifications to external organisations as required.
  • There were robust arrangements in line with data security standards for the availability, integrity and confidentiality of patient identifiable data, records and data management systems.

Engagement with patients, the public, staff and external partners

The service involved patients and staff to support high-quality sustainable services.

  • The service encouraged and heard views and concerns from patients and staff and acted on them to shape services and culture.
  • Staff could describe to us the systems in place to give feedback, for example during annual appraisals. We saw evidence of feedback opportunities for staff and how the findings were fed back to staff. We also saw staff engagement in responding to these findings.

Continuous improvement and innovation

There were systems and processes for learning, continuous improvement and innovation.

  • There was a focus on continuous learning and improvement. For instance, we saw evidence the service invited specialist clinicians to clinical meetings where staff were able to learn about innovations and emerging technology in primary and secondary care.
  • The service made use of internal and external reviews of incidents and complaints. Learning was shared and used to make improvements. When the service carried out a clinical audit following a patient safety alert about a particular medicine, it shared its findings with the medicine distributer with a view to contributing to wider learning.
  • Leaders and managers encouraged staff to take time out to review individual and team objectives, processes and performance.