Brinsley Avenue Practice

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

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

This service scored 79 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff had not contributed to the development of the practice vision and strategy. The practice was aware of future challenges and had taken action to address them. For example, the expansion of the service across 2 sites to meet the expanding population.

Staff told us there was an open and transparent culture within the practice and they were actively encouraged to raise concerns and that those concerns were listened to and acted on. Leaders and staff told us there was a no blame culture within the practice.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Staff told us leaders in the practice were very approachable and responded to any concerns raised. Staff also told us leaders modelled the values of the practice. For example, the practice manager worked alongside reception staff sometimes, so they were visible and easy to approach. We saw the leadership team worked with other practices in the primary care network and were engaged in the development of primary care services within the local area. Staff gave examples of when they had been supported by leaders within the practice. For example, phased returns after long-term sickness. Leaders told us how a member of staff suffered a bereavement and it highlighted that a formal compassionate leave policy was not in place within the practice. As a result of this they developed a policy to ensure that staff were supported with compassionate leave when it was appropriate to do so.

The service fostered a positive culture where people felt they could speak up and their voice would be heard and acted on.

The practice had established external Freedom to Speak up arrangements. Most staff were aware of how to raise concerns. We saw there were contact details for staff to refer to in clinical and non-clinical rooms.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Policies and procedures to promote diversity and equality were in place. Staff described an open and positive working environment where staff felt everyone was valued and supported. They told us there was a friendly, inclusive team atmosphere. Staff also told us there was a no-blame culture at the service.

The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate. The service maintained a risk log to clearly capture known risk, actions taken to mitigate them and to provide oversight.

Leaders and managers supported staff, and staff we spoke with were clear on their individual roles and responsibilities. The provider had established governance processes that were appropriate for their service. However, the overarching governance was managed at the branch practice, rather than the main site, due to more available space. Staff could access all the required policies and procedures. Managers held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks. Managers clearly recorded any actions arising from these meetings and ensured they shared these with staff. Systems were in place for the effective handling of significant events, risks and safeguarding. Staff took patient confidentiality and information security seriously and had completed training to support them in this.

The service understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners such as the Primary Care Network (PCN) and collaborated for improvement.

The service worked with other practices within their PCN to offer extended access appointments. They held a community breast pain clinic and the men’s mental health clinic within the practice. They had extended their spirometry service for the management of chronic pulmonary obstructive disease (COPD) to other practices within the PCN. Staff had made adjustments to improve coordination of their service including contacting people over the age of 70 who had not been seen within the practice over the previous 12 months to try to avoid potential hospital admissions.

We spoke with representatives from 5 care homes where the service provided care and treatment. They told us that they had an excellent working relationship with the practice.

The practice supported an initiative called Warm Spaces for people who lived on their own and were at risk of social isolation.

The service worked closely with the Patient Participation Group (PPG). A representative from the PPG told us the practice listened to their concerns and acted on them.

The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The practice had a quality improvement plan in place to help drive improvements in services. All staff were encouraged to put forward and test out new ways of working.

The practice had carried out single cycle and second cycle audits to assess care and identify learning to improve outcomes for people. We saw learning from audits had improved outcomes for people, for example, when carrying out minor surgery and the prescribing of a medicine used in the treatment of osteoporosis.

The practice had worked with a hospital consultant to improve health outcomes for people with Chronic Obstructive Pulmonary Disease (COPD) and as a result, implemented a spirometry service within the practice. This was rolled out to other practices within the Primary Care Network to help to improve health outcomes in the local area.

The practice had influenced improvements to people’s health at a national level. For example, they had participated in a 3-part research project for chronic kidney disease, which affects approximately 11% of the global adult population. It included lifestyle advice, blood pressure monitoring and the development of a protocol to improve health outcomes for people. They presented their findings at a national conference during UK Kidney week 2026 to influence patient care on a national basis. For example, how to improve early diagnosis, coding and detection of disease progression. They had developed posters to promote this work.

GPs had published research papers in national journals to improve outcomes for patients. For example, investigation into Pink disease and mercury poisoning.