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Inspection Summary

Overall summary & rating


Updated 30 April 2015

Letter from the Chief Inspector of General Practice

Brannel Surgery was inspected on Wednesday 4 February 2015. This was a comprehensive inspection.

We found the practice to be good for providing well-led, safe, effective, caring and responsive services. It was also good for providing services for the six population groups.

Our key findings were as follows:

There were systems in place to address incidents, deal with complaints and protect adults, children and other vulnerable people who use the service. Significant events were recorded and shared with multi professional agencies. There was a proven track record and a culture of promptly responding to incidents and near misses and using these events to learn and change systems changed so that patient care could be improved.

There were systems in place to support the GPs and other clinical staff to improve clinical outcomes for patients. According to data from the Quality and Outcomes Framework (the annual reward and incentive programme detailing GP practice achievement results) outcomes for patients registered with this practice were equal to or above average for the locality. Patient care and treatment was considered in line with best practice national guidelines and staff are proactive in promoting good health. There were sufficiently skilled and trained staff working at the practice.

The practice was pro-active in obtaining as much information as possible about their patients which does or could affect their health and wellbeing. Staff knew the practice patients well, are able to identify people in crisis and are professional and respectful when providing care and treatment.

The practice planned its services to meet the diversity of its patients. There were good facilities available, adjustments were made to meet the needs of the patients and there was an effective appointment system in place which enabled a good access to the service.

The practice had a vision and informal set of values which were understood by staff. There were clear clinical governance systems and a clear leadership structure in place.

We found an outstanding area of practice:

  • The practice had developed a relationship with the Police Community Support Officer who referred patients that he has had concerns about in the community. This had been very useful in averting crisis situations before they had escalated.

There were areas of practice where the provider should make improvements.

The provider should:

  • All clinical staff should receive training in the Mental Capacity Act (2005). The MCA is a legal framework which supports patients who needs assistance to make important decisions.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas



Updated 30 April 2015

The practice is rated as good for providing safe services.

Patients we spoke with told us they felt safe, confident in the care they received and well cared for.

There were sufficient numbers of staff working at the practice. Staffing and skill mix were planned and reviewed so that patients received safe care and treatment at all times.

Staff turnover was low. Recruitment procedures and checks were completed on permanent staff as required to help ensure that staff were suitable and competent. Induction procedures for staff, including locum GPs were detailed.

Significant events and incidents were responded to in a timely manner and investigated systematically and formally. There was a culture to ensure that learning and actions were communicated following such investigations.

Staff were aware of their basic responsibilities in regard to safeguarding and the Mental Capacity Act 2005 (MCA). However, not all staff had received MCA training. All staff had received appropriate training in safeguarding adults and children. There were safeguarding policies and procedures in place that helped identify and protect children and adults who used the practice from the risk of abuse.

There were arrangements for the efficient management, storage and administration of medicines within the practice and within the dispensary. Prescription stationary was stored and used effectively and in an appropriate way.

There were clear processes to follow when dealing with emergencies. Staff had received basic life support training and emergency medicines were available in the practice or within GP bags. Checks on these medicines were performed by dispensing staff.

The practice was clean, tidy and hygienic. Arrangements were in place that ensured the cleanliness of the practice was consistently maintained. There were systems in place for the retention and disposal of clinical waste.



Updated 30 April 2015

The practice is rated as good for providing effective services.

Systems were in place to help ensure that all GPs and nursing staff were up-to-date with both National Institute for Health and Care Excellence (NICE) guidelines and other locally agreed guidelines. GPs, nursing staff and dispensary staff used clear evidence based guidelines and directives when treating patients. Evidence confirmed that these guidelines were influencing and improving practice and outcomes for patients.

The practice used the national Quality Outcome Framework (QOF- a national performance measurement tool) scheme. Data provided data to show that the practice was performing equally or slightly higher when compared to neighbouring practices in the Clinical Commissioning Group (CCG).

People’s needs were assessed and care was planned and delivered in line with current legislation. This included assessment of capacity and the promotion of good health. Staff had received training appropriate and in addition to their roles. Effective multidisciplinary working was evidenced.

Regular completed audits were performed of patient outcomes which showed a consistent level of care and effective outcomes for patients. We saw evidence that audit and performance was driving improvement for patient outcomes.

There was a systematic induction and training programme in place with a culture of further education to benefit patient care and increase the scope of practice for staff.

The practice worked together efficiently with other services to deliver effective care and treatment.



Updated 30 April 2015

The practice is rated as good for providing caring services.

The practice was small compared to the national average. Both staff and patients said this helped with communication and provide a personal service. Feedback from patients about their care and treatment was consistently positive. The comment cards we received, a friends and family survey from December and January and survey data from 2014 reflected this feedback. Patients described the practice as caring and said they trusted the GPs and knew them well.

We observed a person centred culture and found strong evidence that staff were motivated and inspired to offer kind and compassionate care and worked to overcome obstacles to achieving this. We found many positive examples to demonstrate how people’s choices and preferences were valued and acted on.

Accessible information was provided to help patients understand the care available to them.

Patients said they were treated with compassion, dignity and respect and they were involved in care and treatment decisions.



Updated 30 April 2015

The practice is rated as good for providing responsive services.

We found the practice had a proven track record of learning from and responding in a timely way well to patient feedback, complaints, incidents and informal comments.

Patients said they could get an appointment easily in advance or with a GP on the same day but sometimes had to wait a little longer to see the GP of their choice. There were no female GPs at the practice, but the GPs had ensured that practice nurses were skilled and knowledgeable in women’s health issues.

The practice reviewed secure service improvements where these were identified. For example, a scheme to prevent unnecessary hospital admissions.

There was an accessible complaints system with evidence that the practice responded quickly to issues raised even if they were verbal informal complaints. There was evidence of shared learning, by staff and other stakeholders, from complaints.



Updated 30 April 2015

The practice is rated as good for well led.

The practice had a vision and strategy which included providing a supportive accessible service within the confines of a rural community.

Staff were clear about the vision and their responsibilities in relation to this. There was a clear leadership structure and staff felt supported by management.

The practice had a number of policies and procedures to govern activity. There were systems in place to monitor and improve quality and identify risk. The process of clinical governance was robust and there was a culture of wanting to improve and learn following any significant event or complaint. Action and learning was shared with the whole team.

The practice learnt from events and complaints and welcomed feedback from patients through the suggestion box and surveys. The practice had an active patient participation group (PPG) who considered themselves to be a critical friend of the practice. Staff had received induction training, regular performance reviews and attended staff meetings and events.

Checks on specific services

Older people


Updated 30 April 2015

The practice is rated as good for the care of older people.

All patients aged 75 and over had a named GP but were able to choose an alternative if they wished or if this was more convenient for the patient.

Pneumococcal vaccinations and shingles vaccinations were provided for older people. Housebound older patients receive immunisations at home where necessary.

The practice did not provide specific older person clinics. Treatment was organised around the individual patient and any specific condition or need they had. A computer pop up alert system prompted clinicians to offer any tests or routine monitoring.

The practice worked with the community multidisciplinary team to identify patients at greater risk of admission. Practice nurses and GPs worked with the community nursing team to provide a streamlined service.

The practice identified older patients with life-limiting conditions and co-ordinated a multi-disciplinary team (MDT) for the planning and delivery of palliative care for people approaching the end of life.

Family and Carers were included in consultations where patients requested. The practice communicated with family members (with consent) to clarify information or inviting them to come along with the patient.

The GPs worked to avoid unnecessary admissions to hospital and used care plans which were reviewed every three months to avoid patients being admitted to hospital unnecessarily.

People with long term conditions


Updated 30 April 2015

The practice is rated as good for the care of people with long term conditions.

The practice had a system to identify patients with long term conditions and arrange treatment, reviews and follow up care at a time suitable to the patient. Patients with long term conditions described the practice as efficient and organised when arranging care and treatment and said the practice reminded them of upcoming health care and medicine reviews.

Patients with diabetes were reviewed by the practice staff and community nurse specialist where required. These reviews included a medicines check, health and lifestyle advice, blood tests and foot care. There were clear guidelines and care templates for GPs and practice nurses to follow.

Patients with long term conditions had personal care plans in place. Respiratory and diabetic clinics were run by practice nurses with specialist qualifications. The nurses attended educational updates to make sure their lead role knowledge and skills were kept up to date.

The practice have effective links with the specialist nursing teams and regularly liaise with the heart failure specialist nurse, community psychiatric nurse, respiratory nurse and diabetic specialist nurse. The diabetic specialist nurse holds joint clinics within the practice on a monthly basis. The practice offer in house diabetic retinal screening on several dates throughout the year.

The practice provided clinics for asthma and chronic lung disorders (COPD) including using spirometry, a lung capacity test, as part of its service to assess the evolving needs of this group of patients.

The practice promoted independence and self-care for patients with long term conditions. For example, some patients monitored their own health remotely and contacted the practice should their symptoms change. The practice had ambulatory BP machines and a range of digital machines that could be loaned to patients should it be clinically necessary.

The computer system contained health promotion prompts so opportunistic screening could take place regardless of for the reason for the patient’s attendance.

All patients with complex needs who were in receipt of a care plan were contacted by the practice following any admission or attendance at A&E and home visits were undertaken if required to ensure medicine reviews were performed.

The practice sent ‘special messages’ to the out of hour’s providers about patients with complex needs and those at the end of their life so the out of hour’s service was aware of their care and treatment.

The practice used the Quality and Outcomes Framework (QOF) which is a national performance measurement tool. The practice used the QOF to identify and support patients with long term conditions to ensure their needs were monitored and gave assurances that they were providing care to set practice standards and working within NICE Guidelines.

Families, children and young people


Updated 30 April 2015

The practice is rated as good for the care of families, children and young people.

The practice held weekly baby and child immunisation appointments and sent letters of invitation to all parents and carers.

Patients who did not attend for their immunisations were reviewed by the practice nurse and GP and contacted by the practice if required. If there were any concerns regarding the reasons for non-attendance these are raised with the health visitor who visited the practice once a week and was able to speak with practice staff on a daily basis should it be necessary.

Ante-natal care was provided at the practice. Midwives communicated with the GPs and practice team on a daily basis should this be necessary. The practice staff also worked with health visitors, dieticians, school nurses and podiatrists.

Patients had access to contraception advice and had access to a full range of contraception services including the insertion of implants. Patients could also access chlamydia testing and cervical screening. There were private areas for women to use when breastfeeding.

All nurses and GPs were competent to take blood from children to avoid long journeys to hospitals.

The practice provided a room and worked with a local charity, who offer counselling to bereaved children.

Appropriate systems were in place to help safeguard children or young people who may be vulnerable or at risk of abuse. All staff had received training on safeguarding children and young people.

The practice made sure they are ‘young people friendly’, for example, in respect of confidentiality and consent, an easy to access service, a welcoming environment and staff trained on issues that young people face. The practice supports the C-Card scheme. The C-card is given so that a younger person can get free condoms at different places across Cornwall & the Isles of Scilly.

Working age people (including those recently retired and students)


Updated 30 April 2015

The practice is rated as good for the care of working age people.

The practice offered telephone consultations and four week advanced booking for appointments. Evening appointments were also available.

NHS Health checks, weight checks, healthy living advice, blood pressure checks, new patient checks and smoking cessation appointments were offered at a time convenient to the patient.

There was an online appointment booking system and online prescription request via the practice website which patients said was easy and convenient to use. Patients who received repeat medicines were able to collect their prescriptions at a pharmacy of their choice or at the practice dispensary if appropriate.

The practice offered travel advice and vaccinations. Nurses who provided this service had received specialist training.

Physiotherapy services were available to patients at various locations around Cornwall so patients could book with a Physiotherapist near to where they work.

People whose circumstances may make them vulnerable


Updated 30 April 2015

The practice is rated as good for the care of people whose circumstances may make them vulnerable.

The practice had a register to identify patients with a learning disability. A health care assistant provided learning disability health reviews to ensure health needs were met in a more relaxed and appropriate environment. A carer usually attended these reviews for support and to ensure the patient’s views and concerns are taken into consideration. If necessary, these patients were visited at home if they chose.

The practice had a protocol for safeguarding of vulnerable people and had an appointed adult safeguarding lead. All members of staff had received training in safeguarding and were aware of how to identify abuse and knew what action to take if abuse was suspected. There was easy access to guidance when information was required. Adults being identified as vulnerable had an appropriate easily identifiable note on their electronic records to make this easily recognisable to any health care professional meeting with that person.

The GPs referred any vulnerable patients to the community matron and dementia liaison member of staff for support.

People experiencing poor mental health (including people with dementia)


Updated 30 April 2015

Patients on the practice mental health register are offered annual health checks which focus on general physical health. This includes ensuring they are up to date with routine screening and vaccinations.

The practice used QOF to ensure mental health checks and medicine reviews were conducted to ensure patients received appropriate doses and care plans were in place. Blood tests were regularly performed on patients receiving certain mental health medicines.

The practice have in-house counsellors with very short waiting lists and access to counselling outside of the practice in various locations for patients who prefer not to come to the practice or wish to be seen outside of working hours.

Staff at the practice promote a local stress buster course which is held locally and on a regular basis. GPs keep counselling self-referral packs and actively signpost patients to local groups, such as the Memory Cafes and a local mental health charity which offers structured activity to promote positive wellbeing.

The practice offer rooms for local mental health workers to see patients at the practice to try and make it as easy as possible for patients to access services.

All the clinicians were aware of the link between physical and mental health and encourage subsidised exercise referral programmes and local walking groups.

The practice had a dementia register and were aware that the practice numbers for dementia were quite low despite completing a recent audit.