The Brimington 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.

At our last assessment, we rated this key question as Good. At this assessment, the rating has changed to requires improvement.

This service scored 59 (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 had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. Representatives from the Patient Participation Group (PPG) felt the provider took concerns seriously and proactively made improvements to the service.

Staff told us that leaders actively encouraged staff to raise concerns when things went wrong. Staff were able to provide examples of when significant events had occurred and the learning from them. For example, following the mislabeling of a specimen pot, systems were changed so that staff no longer wrote on the pots but printed labels to attach to them. A system of double checking the labeling of specimens was also introduced.

During staff meetings, the whole team discussed and learnt from clinical issues. Staff told us there was a very open culture, and that safety was a top priority. The provider had processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Learning from incidents and complaints resulted in changes that improved care for others.

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.

There were systems in place for processing information relating to new patients. The service worked with other providers to deliver shared care and when people moved between services. Referrals and test results were managed in a timely way. There were systems in place to ensure that 2 week-wait referrals for potential cancer were carried out in a timely manner.

However, our remote searches identified 132 pending electronic letters. One dated back to September 2023 and there was a total of 43 letters between that date and 31 October 2025. On the day of our subsequent onsite visit, we found that some action had been taken, and the oldest letters had been dealt with. There was no patient harm as a result of this delay. The provider told us they were reviewing the administration support currently in place to address the volume of work letters into the practice generated.

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 bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Safeguarding policies were in place and known to staff, who had received training in safeguarding procedures. The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations. Following feedback from our remote searches, we found the service had taken appropriate action to ensure that alerts were added to the records of people living in the same household as those with a known safeguarding concern. Staff were aware of the safeguarding leads within the practice.

There were systems in place to follow up frequent attenders to the emergency department and children who failed to attend appointments in secondary care or childhood immunisations. Regular clinical meetings took place where this is group of people were discussed. Regular audits were conducted to review safeguarding lists and action plans were produced.

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.

Emergency equipment was available and maintained. The defibrillator was situated on an outside wall of the practice. This meant that the local community had access to this if assessed as appropriate when someone called the 999 service. Staff could recognise a deteriorating patient and knew of the action to take. They had been supported to do this through training such as sepsis awareness and cardiopulmonary resuscitation. People were advised on risks related to their condition and the actions to take if their condition deteriorated.

The service mostly detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Contracts were in place to ensure the premises were maintained. Most of the required health and safety risk assessments and audits had been undertaken and risks identified had been addressed. There was a business continuity plan in place which was monitored and reviewed.

Blind hoops were not always secured to walls in line with national safety alerts. Monthly checking of the emergency lighting had not been completed in line with their policy.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together effectively to provide safe care that met people’s individual needs.

There were a range of clinical and non-clinical roles within the practice. We found training was mostly up to date, learning needs and development of staff were managed appropriately, and staff were working within their agreed areas of competence. Staff received annual appraisals and told us they found these very supportive and helped them to identify training needs. Staff were given protected time to complete essential training or, given time off in lieu if they completed training in their own time. Safe recruitment practices were followed.

Non-clinical staff, such as receptionists, had only completed level 1 training for safeguarding children. The provider acknowledged level 2 was more appropriate and amended their training schedule to reflect this and ensure staff completed the appropriate level of training.

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Cleaning schedules for both cleaners and clinical staff were in place however, signed copies were not always available to demonstrate they had been followed. An infection prevention and control (IPC) audit had not been completed since 2023 and some of the issues identified in this audit had not been addressed. For example, cracked and flaky plaster on the walls.

Our review of staff files identified 3 out of the 4 files did not include a complete immunisation history to protect staff against potential health care acquired infections. Staff had received immunisations for hepatis B however, there was no evidence to demonstrate the required blood test had been completed to confirm immunity to hepatitis B. Risk assessments had not been completed to mitigate either of these potential risks.

A programme of cleaning curtains and carpets was not in place. Clinical sinks had overflows and action to mitigate potential risks had not been identified. We found out of date sterile surgical instruments, dating back to 2022, in the minor surgery room. We observed that staff did not always comply with the practice’s IPC and uniform policies. Control of Substances Hazardous to Health (COSHH) risk assessments were not in place for all of the cleaning solutions used in the practice and a recent legionella risk assessment had not been completed, although there was clearly documented evidence that water temperature checks and remedial work had been completed.

The provider told us due to a previously unstable practice nurse team they had not had the capacity to address all of these issues. They felt confident that now the nursing team was up to capacity these issues would be addressed. They told us they would source an external company to complete a new IPC audit and complete a legionella risk assessment when the new building work was completed. The provider told us they would work with the Integrated Care Board (ICB) to mitigate potential risks.

The practice had a newly appointed infection, prevention and control (IPC) lead and staff had received appropriate training. Hand washing audits had been completed in October 2025 and action taken were required. For example, making staff aware of the need to cover scratches on hands with waterproof plasters and that gel or false nails were not permitted.

Our remote searches showed that the service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. However, during a subsequent onsite visit, the service was found to have been extremely proactive in addressing both individual and system wide concerns that had been identified.

Our remote searches identified a small number of people prescribed a medicine used in the treatment of high blood pressure who had not received the required monitoring. Despite frequent recalls, people had not attended for monitoring. At the time, formal protocols for managing this were not in place. During our subsequent onsite visit, we found the provider had been extremely responsive to these concerns and appropriate action to manage this group of people had been taken. They had also developed a formal non-attenders policy and flow charts, which they embedded into their IT system to alert clinicians.

We found 2 women of childbearing age who had been prescribed a controlled drug with known risks to a developing foetus. A review of their medical records revealed an absence of documented discussions regarding pregnancy risks or the use of effective contraception. Our subsequent on-site visit confirmed that appropriate action had been taken to mitigate these risks. Furthermore, a new protocol had been added to the practice’s IT system that alerted clinicians to this potential risk at the point of prescribing.

National data showed that the prescribing of a group of controlled drugs used in the treatment of pain was above the national average. During our remote searches, we identified 107 people prescribed these medicines who potentially had not received a review in the last 12 months. Three out of the 5 records we looked at were overdue a review of which 2 were overdue by 2 years. The provider told us that a structured plan was already in place for the pharmacy team to review people prescribed these medicines. At our subsequent onsite visit, we found the provider had been extremely responsive to our concerns and that appropriate action had been taken to review these people.

Systems for monitoring people prescribed medicines used in the treatment of rheumatoid arthritis were effective.

However, our remote clinical searches identified that Medicines and Healthcare products Regulatory Agency (MHRA) guidance was not always followed. For example, a particular class of medicine usually used in the treatment of diabetes. We reviewed the records of 5 of the 107 people prescribed these medicines and found that it was not clear in the records of 2 of these people if they had been made aware of the potential risks associated with these medicines. The provider told us they planned to add an automated system to their IT system to prompt clinicians to code this.

Our remote searches identified that only 26.1% of people prescribed long-term medicines had received a medicine review in the last 12 months. Only 35.3% had in the last 18 months.

A new system had been put in place to enable staff to manage prescription stationery appropriately and securely. We found that prescription stationery was not always destroyed in line with national guidance. Following our assessment, the provider sent us an updated protocol for the tracking and shredding of prescription stationery.

Medicines were stored securely and mostly at appropriate temperatures. However, we found that a cold chain breach had occurred in a vaccine fridge on 29 October 2025. The service was unable to locate the data logger readings for this date to provide evidence about how long the temperature range had been breached. They told us it was for a brief period of time due to adding new stock to the fridge.

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. There was a system of 6-monthly audit and clinical supervision in place to support non-medical prescribers.

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 and completed required safety risk assessments. The provider had effective systems to manage and respond to medicine recalls.

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 indicators for the prescribing of different groups of antibiotics were in line with national averages.