The Brooke Surgery

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

We looked for evidence that the service met people’s needs, and that staff treated people equally and without discrimination.

At our last assessment, we rated this key question as Good. At this assessment, the rating remains the same.

This service scored 86 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service ensured people were at the centre of their care and treatment choices, and they decided, in partnership with people, how to respond to any relevant changes in people’s needs.

The provider had systems and protocols in place to ensure that they were able to offer tailored appointment times to individual needs. The system had been implemented and was understood and followed by all staff arranging appointments. There were different appointment lengths available which allowed patients with complex health needs or those with Learning Disabilities or Mental Health needs to be given extra time to discuss needs during a health review appointment.

Our review of clinical records showed patients were supported to understand their condition and were involved in planning for their care needs. They were also involved in decisions about their care.

Feedback from patients via CQC’s give feedback on care showed overall people felt staff treated them equally and without discrimination.

The service had undertaken Pride in Practice training and had achieved Gold award reaccreditation. Pride in Practice is an award-winning initiative run by the LGBT Foundation that works with primary care services. The service had committed to extend training of pride in practice to all new staff. This shows commitment to the programme and ensures that all staff are trained to the same level and means that patients can expect the same level of person-centred care no matter who it is that they are seen by at the service.

The service promoted its staff to complete mandatory training on dementia awareness. The service overall has achieved a high percentage of staff being trained in dementia awareness.

The service had an exceptional understanding of the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

We saw the practice worked in partnership with other services to meet the needs of its patient population. The practice had tailored its services to meet the diverse needs of its community, for example, building relationships with community groups to promote the take up of screening programmes. They did this by working closely with the local mosque and promoted immunisations and worked to break down some of the barriers and explained the risks of patients and their families not taking immunisations. The provider hoped that this would aid them in eventually reaching national targets.

There were established mechanisms for engaging with the community healthcare provider. The provider promoted blood pressure, diabetes and lipids checks within the form of a Point of Care Treatment bus and by also attending a local mosque. This allowed for a single appointment where bloods could be taken, tested and results given on the same day. This was promoted on local social media groups as well as through the practice website and via text messages to service users. The idea was to test people in hard-to-reach groups and those that had not been as engaged in the service as they needed to be and could be at risk of developing long-term conditions.

The service used the bus in the local community which was run for 8 days and enabled the provider to see 1002 patients. Of these 1002, 20 patients were diagnosed with either hypertension or diabetes. The service was able to deliver over 150 vaccinations, identified over 100 patients at being of cardiovascular risk and was an immediate point of care. They offered blood tests with the ability to give real time results in some circumstances undertake review of patients on statins. The bus reached out to service users that had for one reason, or another not been engaged with the service. Overtime was paid to staff and clinical and non-clinical staff that were involved. The provider was able to use technology to immediately input information on to the patients records and reduced the time completing this work later. Feedback received from patients who accessed the bus was mainly positive. The provider took on feedback where some people felt it was disjointed and would make changes and build on the success of this initiative.

The service was exceptional at developing appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

The service had composed online videos which were shared to the practice's online channel. There were a total of 149 videos shared and covered a range of subjects including how to help with sleep, how to recognise and treat hay fever, recognising Sexually Transmitted Diseases (STI’s), how to treat and when to test for STI’s and how to spot the signs of the menopause and ways to help alleviate the symptoms. The service also developed videos on what immunisations are and how they can help protect people. Other subject content included the launch of a mobile phone messaging app which is the triage system used by the service, this was embedded onto the practice website and provided a step-by-step demonstration of how to use the system.

Information to promote the take up of screening and immunisation programmes was available in a range of languages within the waiting area. The practice had access to interpreter services, including British Sign Language. Patients were informed as to how to access their care records. There was information boards located around the practice aimed at men’s health, women’s health and LGBTQ+ individuals.

The service enabled people to share feedback and ideas, or raise complaints about their care, treatment and support. They involved people in decisions about their care and told them what had changed as a result.

We saw complaints were managed in line with the practice’s policy. There was a dedicated member of staff, a Patient Care Specialist, who dealt with complaints. Complaints were fully investigated and appropriate responses were sent to patients.

Learning from complaints was evident and these outcomes were discussed at appropriate meetings. Complaints that involved individual staff members were anonymised before being shared with all staff. Staff were encouraged to make suggestions to improve services following complaints and any suggestions were discussed as a team and new ways of working were agreed. These would be trialled for a certain period of time before being rolled out ensure that real change could be seen from the changes made. Any learning from complaints would then be shared with the Primary care Network (PCN) to enable learning to be shared wider.

While representatives from the Patient Participation Group (PPG) met regularly with the provider and had opportunities to raise concerns, they felt that not all concerns were consistently acted upon or fully rectified.

The service made sure that people could access the care, support and treatment they needed when they needed it.

The provider recently introduced a WhatsApp triage tool and replaces previously used online triage. Service users send a message through to a landline number using a mobile phone messaging app and choose different options presented to them to identify what the reason for contacting the service is and what support they are requesting.

The practice had access to interpreter services, including British Sign Language. Information provided by the service met the Accessible Information Standard. Patients were informed as to how to access their care records. Information on the practice website was available in a range of different languages. The provider employed bi-lingual speaking staff to help reduce the breakdown in communication barrier. The provider supported a proportion of patients from a Bengali speaking background.

Information leaflets were available in the waiting area that covered a wide range of subjects.

Service users whose first language is not English could use the mobile phone messaging app in their own language to communicate with the service. The requests can be for either clerical reasons or due to medical concerns.

Service users could still approach the front desk or call into the practice in the normal way. The provider continually reviewed patient experience of this new system and data showed overall patients were satisfied with the new system.

Feedback from some people using the service told us that, since the introduction of the tool, at times long delays in getting through to the practice on the telephone had been experienced in recent months and it was felt in part due to the number of patients that the provider had taken on. The practice was aware of the issues and following an audit of the telephone system, they had identified key issues and developed an action plan to improve call wait times. The service was in the process of recruiting additional staff and a reception manager to increase capacity.

The latest National GP Patient Survey data showed 71% responded positively saying how easy it was to contact the service with 46% advising how easy it was to get through to the service via the telephone. The national average was 73% and 57% respectively. The percentage of patients who responded positively to the overall experience of contacting the service was 64% compared to the national average of 77%.

The practice held back appointments for the afternoon, should they be needed following patient's triage. Children and vulnerable patients would be reviewed by an appropriate clinician on the same day. Treatment rooms were available on the ground floor and a ramp and automatic door had been fitted to the entrance.

Staff and leaders were innovative in how they listened to information about people who are most likely to experience inequality in experience or outcomes. Staff and leaders actively used this information to provide exceptionally tailored care, support and treatment in response to this.

The provider had a robust system to run searches of patient records to help identify patients with multiple health issues. This was a proactive approach rather than waiting for this cohort of patients to request appointments.

The provider incorporated targeted Point-of-Care Testing (POCT), and translated information into multiple local languages, and brought clinical interventions into trusted community spaces (such as the local mosque).

The service used an IT system designed specifically to identify patients with long term conditions for recalling back in for monitoring. By using this system there was an improvement of experience and outcomes for patients. The system worked in an automatic way once an algorithm had been put in place. The provider saw an increase of 5146 in 2024 – 2025 to 36987 in 2025 – 2026 which equates to an increase of 619% text messages being sent to patients which converted into a 179% increase in booking via the link that was sent. There was an increase of diabetic patients receiving regular monitoring from 63% during 2025 - 2025 to 71% during 2025 – 2026 and BP monitoring from 82% during 2024 – 2025 to 88% during 2025 - 2026.

Feedback provided by people using the service, both to the provider as well as to CQC, was mixed. Of the 81 individual pieces of feedback received directly to CQC 57 were positive for access and feeling that staff treated them equally and without discrimination. Leaders proactively sought ways to address any barriers to improving people’s experience and worked with local organisations, including within the voluntary sector, to address any local health inequalities, building on the point of care bus and work with local faith groups

Staff understood the importance of providing an inclusive approach to care and made adjustments to support equity in people’s experience and outcomes.

Staff working for the provider identified severe regional health inequalities, (69.2% adult obesity rates), within the local community. To help combat the health inequalities being faced by the local community the provider moved its clinical delivery team directly into a local mosque. The provider used accessible aids to support education for the community. This showed the provider worked innovatively to help improve outcomes for individuals.

The provider had processes to ensure people could register at the practice, including those in vulnerable circumstances such as homeless people and travellers. Staff used appropriate systems to capture and review feedback from people using the service, including those who did not speak English or have access to the internet.

People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

Our records review showed people were supported to consider their wishes for their end-of-life care, including cardiopulmonary resuscitation. This information was shared with other services when necessary.

Relatives were involved in these discussions as much as people wanted them to be. The provider took into consideration the mental capacity of individuals when it came to making these informed decisions.

The provider worked closely with the families of patients following the death of a loved one to ensure that their wishes and funeral arrangements could be carried out in a timely manner and without unnecessary delay. The provider also collaborated closely with Muslim funeral directors to minimise delays in the funeral process, supporting the timely observance of religious customs and helping to reduce distress for bereaved family members. The provider showed a commitment in helping people and their families or carers to explore and record their wishes about care at the end of their life and to plan how they will be met so that they feel consulted, empowered, listened to and valued.