During an assessment under our new approach
Date of inspection: 8 and 9 October 2025. Brunswick Park Family Practice is a GP practice and delivers service to approximately 7,600 people under a contract held with NHS England. Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the 3rd decile (3 of 10). The lower the decile, the more deprived the practice population is relative to others. This inspection 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 a good learning culture and people could raise concerns. Managers investigated incidents thoroughly. 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. 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. Staff managed medicines well and involved people in planning any changes in most cases. However, we saw that some medicines were not monitored in line with National Institute for Health and Clinical Excellence (NICE) or other relevant guidelines.
People were involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs in most cases. However, we saw that people with diabetes were not consistently diagnosed or treated in line with NICE or other relevant guidelines. Care was based on latest evidence and good practice. Staff worked with all 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 took decisions in people’s best interests where they did not have capacity. The service was not able to demonstrate cyclical audit showing improving outcomes for people.
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. The service supported staff wellbeing.
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 and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible, knowledgeable and supportive, helping staff develop in their roles. Staff felt supported to give feedback and were treated equally, free from bullying or harassment. Staff understood their roles and responsibilities. Managers worked with the local community to deliver the best possible care and were receptive to new ideas. There was a culture of continuous improvement with staff given time and resources to try new ideas.
There are breaches of Regulation 12 (safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 relating to medicines optimisation, assessing need and monitoring and improving outcomes. The provider will be required to submit an action plan detailing how these breaches of regulation will be addressed.