Brook Health Centre

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. This is the first inspection for this service since its registration with CQC. We assessed all the quality statements from this key question. The practice had systems to assess, monitor and continue to improve the quality and safety of service. There were processes for monitoring patients’ health in relation to the use of medicines including medicines that require regular reviews. We found some of these systems and processes needed review to reduce potential risks to patient safety. There were processes in place to monitor staff training. This key question has been rated as Good.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice 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. Managers encouraged staff to raise concerns when things went wrong. Staff felt there was an open culture. The provider had processes for staff to report incidents, near misses and safety events. Significant event reporting forms were available to all staff to access from the practice computer system. Staff were provided with access to a Freedom to Speak Up Guardian. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. The leadership team reviewed complaints and learning events annually to see if there were trends that needed further action or investigation. Learning from incidents and complaints resulted in changes that improved care for others.

The practice 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 practice commissioned an external company to support with new registrations and was expanding its administrative team to support this fully in-house in the future. The service worked with other providers to deliver shared care when patients moved between services. Referrals and test results were managed in a timely way. We saw that all urgent 2 week wait referrals were followed up to ensure that the patient had received an appointment. Letters and test results were managed effectively and efficiently and we did not identify any delays in managing information.

The practice utilised digital tasks on its computer system to support effective management of clinical and administrative actions. We found there was a significant number of tasks outstanding. Upon further investigation it appeared these tasks were being used as individual ‘to-do’ lists. Although we did not identify any significant risks to patient safety, following our discussions with the practice, the leadership team advised they had already identified this as a potential risk area and had changed their protocols to ensure urgent matters were not entered as tasks. Following our assessment, the practice provided an updated standard operating procedure that clearly documented this process.

The practice 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. There was an experienced, engaged and capable safeguarding lead supported by a recently appointed deputy, and a safeguarding administrative lead. Safeguarding policies were in place, comprehensive, up-to-date and regularly reviewed. All staff understood their responsibilities around safeguarding and were appropriately trained in safeguarding procedures. A random sample of staff files we reviewed showed all staff had a suitable Disclosure and Barring Service (DBS) checks based on the role and responsibilities of the job and had completed adult and child safeguarding training at the recommended level, with refresher training at the appropriate frequency.(DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable).The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations. Regular safeguarding meetings were held with the local multidisciplinary team such as health visitors. Staff were aware of safeguarding issues specific to their practice population. Appropriate clinical coding was used to flag people on the safeguarding register and their family members.

The practice 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. In the 2025 national GP patient survey, 95% of people who responded said they were involved as much as they wanted to be in decisions about their care and treatment. This was above the national average of 91%. Staff could recognise a deteriorating patient and knew of action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated. There was always a duty GP available if they needed urgent advice. Emergency equipment was available and maintained. However, we found discrepancies in record keeping for emergency equipment where the log sheets did not accurately reflect the location of one item. The practice team were able to correct this during our assessment. Following feedback received during the assessment, the practice reviewed the accessibility of the emergency medicines and equipment to ensure they were satisfied items were readily available in an emergency.

The practice detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. There was a business continuity plan in place which was monitored and reviewed. Contracts were in place to ensure the premises were maintained. Health and safety risk assessments and audits had been undertaken and risks identified had been addressed. We observed fire exits were clear and fire safety equipment was easily available and regularly checked. Staff were aware of what to do in an emergency and where emergency medicines and equipment were stored. Allocated staff also knew how to safely manage spillages of bodily fluids. We observed that the clinical rooms and offices used by the GP practice were fit for use and there were room checks undertaken. All equipment had been checked and calibrated as required. An electrical safety inspection was undertaken during our assessment. Leaders advised that identified actions would be completed by the landlords of the premises.

Leaders made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked well together to provide safe care that met people’s individual needs. The practice had 5 non-medical prescribers and had established formal processes in place to monitor and audit their clinical practice. This formal process included documented reviews and had commenced in September 2025. A sample of staff files we reviewed showed that all staff were suitably qualified, maintained their professional registrations and their continuing professional development (CPD) and had up-to-date specialist training appropriate to their role. All staff had appraisals, access to regular clinical supervision and protected time to complete their mandatory training. Appraisals for some staff were overdue, and we were informed they would be completed by the end of October 2025. Safe recruitment practices were followed. In the 2025 national GP patient survey, 94% of people said they had trust and confidence in their healthcare professional, this was above the national average of 92%.

The practice assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. The leaders ensured that facilities and equipment were safe, and that equipment was maintained according to manufacturers’ instructions. The practice had a designated infection, prevention and control (IPC) lead and all staff had completed relevant training. Cleaning schedules were in place and followed. Risk assessments and audits were undertaken; however some were incomplete. The practice had invited the IPC lead at the Integrated Care Board (ICB) to undertake an audit to establish the correct format for the audit and baseline requirements and actions. During our assessment, we found there were 2 consultation rooms which had carpeted flooring, as did the waiting room which was not mentioned in the most up to date IPC audit. Staff advised the cleaning company undertook deep cleans of the carpeted area and carpet tiles were easy to replace if and when needed. The practice was unable to provide a completed IPC audit for the branch location. Immediately following our assessment, the practice submitted an up-to-date audit which considered the carpeted rooms and any potential actions required to mitigate risks. A completed IPC audit for the branch site was also provided. We also found curtains around clinical couches had not been changed in line with guidance as set out in the National Standards of Healthcare Cleanliness 2025. Following our assessment the practice provided evidence that appropriate action had been taken and updated standard operating procedures had been introduced to prevent the rick or recurrence.

The practice was able to demonstrate that it had an employee immunisation programme. Records of staff immunisation status were maintained. All staff received an occupational health assessment which included a review of their immunisation needs. Where required a risk assessment was undertaken for individual staff. The practice advised that due to delays with the local occupational health service some new members of staff were still awaiting their occupational health assessments. These staff had received risk assessments and where required, adjustments to their roles had been made to reduce risks.

The practice made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

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.

Staff managed prescription stationery appropriately and securely. We noted the system for logging and recording prescription stationery had been introduced in the weeks prior to our assessment. Leaders advised they had recognised a gap in their system and had worked to embed the new protocols promptly to ensure risks were minimised.

Staff followed protocols to ensure they prescribed all medicines safely, and ensured people received all recommended medicines reviews and monitoring. Medicines were stored securely and at appropriate temperatures. During our assessment, we found gaps in the paper records for checking fridge temperatures at the main practice site. However, these fridges had internal dataloggers which accurately tracked and recorded the temperatures of fridges throughout the day. Although, this mitigated the risks, leaders advised they would be establishing better systems to ensure records were maintained in line with protocol. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines. Waste medicines were recorded and disposed of appropriately including medicines returned by patients. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments. The provider had effective systems to manage and respond to safety alerts and medicine recalls. Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring. There were suitable processes for staff to follow when dispensing medicines. Our review of the dispensary found no areas of concern, with effective systems and protocols in operation. 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 number of antimicrobials issued by the provider was in line with local and national averages. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.