Brookroyd Limited

We carried out an announced focused inspection at Heckmondwike Health Centre (also known as Brookroyd Limited) on 24 and 25 May 2022. At this inspection we reviewed the safe, effective and well-led key questions. We did not specifically inspect the caring and responsive key questions and the ratings of good remain unchanged based on the findings from the last inspection on 14 April 2016.

Following this inspection, we rated the location as good overall, and for the key questions safe, effective and well-led.

Safe - Good

Effective - Good

Caring – Not inspected

Responsive – Not inspected

Well-led - Good

The full report for our previous inspection can be found by selecting the ‘all reports’ link for Heckmondwike Health Centre on our website at www.cqc.org.uk

Why we carried out this inspection

This announced focused inspection was carried out following changes to the provider registration and legal entity of the practice. This was the first inspection since this change.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

• Conducting some staff interviews using video conferencing.
• Completing clinical searches on the practice’s patient records system and discussing findings with the provider.
• Reviewing patient records to identify issues and clarify actions taken by the provider.
• Requesting evidence from the provider.
• A shorter site visit.
• Staff questionnaires.

Our findings

We based our judgement of the quality of care at this service on a combination of:

• what we found when we inspected
• information from our ongoing monitoring of data about services and
• information from the provider, patients, the public and other organisations.

We have rated this practice as Good overall

We found that:

• There were systems in place to safeguard children and vulnerable adults from abuse and staff we spoke with knew how to identify and report safeguarding concerns.
• Leaders reviewed the effectiveness and appropriateness of the care the service provided. They ensured that care and treatment was delivered according to evidence-based guidelines.
• The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
• There was a programme of quality improvement, including clinical audit.
• Staff had the skills, knowledge and experience to deliver effective care.
• Staff involved and treated people with compassion, kindness, dignity and respect.
• The practice operated effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Leaders demonstrated they had the capacity and skills to deliver high-quality, sustainable care.

Whilst we found no breaches of regulations, the provider should:

• Continue to monitor and make improvements to increase the uptake of cervical screening.
• Undertake the fire evacuation drill in line with the findings of the fire risk assessment and guidance.

The evidence supporting our ratings are set out in the evidence table.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care