Brook Health Centre

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

This is the first assessment of this service since its registration with CQC. We assessed all the quality statements from this key question. 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. We found there was an inclusive and positive culture of continuous learning and improvement shared by all staff. Leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated and person-centred. There was a system of governance that aimed to manage risks and keep people safe, however, we found some areas that lacked effective oversight. The leadership team was prompt to respond to feedback received during our assessment and implement improvements where needed. Leaders had a clear business plan and gathered feedback and information about risks, performance and outcomes which they used effectively to make decisions about future developments. This key question has been rated as good.

This service scored 71 (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 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.

All staff had contributed to the development of the practice vision statement of ‘welcoming, supportive and inclusive’. Leaders informed us they regularly communicated with outside bodies like the wider PCN and Integrated Care Board (ICB) to ensure that the practice operated effectively.

The practice 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.

Leaders and staff told us there was an open culture, and leaders were approachable and responded to any concerns raised. The practice offered flexible working arrangements where possible. The leadership team worked with other practices in the PCN and were engaged in the development of primary care services within the local area. Staff we spoke with were aware of those with lead roles in the practice.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. The practice had established Freedom to Speak up arrangements with other practices in the primary care network. Staff were aware of how to raise concerns.

The practice valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them. Policies and procedures to promote diversity and equality were in place. There were robust, fair and transparent recruitment policies and procedures. All staff had completed equality and diversity training. Adjustments had been made to ensure all staff were valued, for example we saw adjustments to support disabled staff were in place.

The practice 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 had systems to monitor risk, performance and outcomes, and share information securely with others when appropriate. However, we found areas that required further oversight as some systems were not working effectively. For example, we found gaps in the infection control audits and inconsistencies in record keeping for emergency medicines and Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) reviews. Some of these areas of improvement, such as DNACPR reviews, had been identified by the leadership team prior to our assessment and we saw evidence that action was underway to improve. For example, training on the use of Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) forms for supporting patients with planning for the future. For other areas, the leadership team were prompt to respond to feedback during our assessment and provided evidence and assurance of actions taken and planned to reduce risks.

Leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Managers met with staff regularly to complete appraisals and performance reviews. Staff could access all 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. Staff took patient confidentiality and information security seriously.

The practice understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The provider worked with other practices within their primary care network (PCN) to offer extended access. Staff had made adjustments to improve coordination of their service with community healthcare services, for example the reestablishment of weekly face to face meetings centred on the care of those receiving palliative care. The practice was involved in meetings with other healthcare providers in the local area to develop the way care was delivered. There was an active and well-established Patient Participation Group (PPG).

The practice 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.

We received positive feedback from staff and patients on the improved appointment system. Leaders discussed plans for further improvements relating to recall systems for patients with co-morbidities. Staff and leaders ensured that people using the practice, their families and carers had opportunities to provide feedback on care received and used this to help drive improvements. We saw there was a proactive approach to auditing and risk assessment, with an active risk register maintained to support effective implementation and oversight of improvements.