Royal Primary Care Brooklyn

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 assessment for this service since its registration with CQC. This key question has been rated as Good.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There was a proactive and positive culture of safety, based on openness and honesty. Staff felt confident to raise concerns and were aware of how to support people to raise concerns. Concerns about safety were investigated and reported. People felt supported to raise concerns and most 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. During clinical meetings, clinicians discussed and learnt from clinical issues. Staff felt there was an open culture, and that safety was a priority. The provider had processes for staff to report incidents, near misses and safety events and feedback from staff demonstrated they were aware of how to do this.

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. Lessons and themes from significant events and complaints were shared across all of the 4 Royal Primary Care practices to continually identify and embed good practice. However, the systems in place for the reporting of significant events did not enable the provider to identify themes at practice level. The day after our assessment the provider told us they had amended their systems to enable this and had plans to move to a new reporting system for significant events.

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 and systems to ensure referrals were made in a timely manner. There was a dedicated team to upload letters from other services into peoples’ records within 48 hours. However, we found 498 letters waiting to be coded dating back 4 weeks. The provider explained there was a target that test results would be reviewed within 5 working days however, our remote searches identified 1,199 pathology results waiting to be dealt with dating back 2 weeks. Following our assessment, the provider sent to us photographic evidence that this number had reduced to 174 results and plans on how the remaining results would be dealt with. The provider told us that they hoped to have a clinical sector lead within the practice to oversee that targets were met. We found 705 open tasks in the practice’s IT system. The provider explained that clinicians used tasks as notes to self.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They shared concerns quickly and appropriately. Staff were appropriately trained in safeguarding procedures at a level appropriate to their role. The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations. Safeguarding policies were in place and known to staff. However, the children’s safeguarding policy did not reflect the categories of abuse recognised in the Children Act 1989. The day after our assessment the provider forwarded to us an updated policy that included this information. We spoke with the safeguarding lead who confirmed that a policy to support staff in the management of female genital mutilation (FGM) was not in place. The day after our assessment the provider forwarded a copy of the Trust’s secondary care FGM policy and told us this would be adopted within the GP practice and staff had been made aware of it.

The service worked with people to understand and manage risks. They provided care to meet people’s needs that was safe and supportive. Emergency equipment was available and mostly maintained. Staff could recognise a deteriorating patient and knew of the actions to take. Reception staff had received appropriate training in the use of a triage tool to identify people in need of urgent care. People were advised of risks related to their condition and actions to take if their condition deteriorated.

The service did not always detect and control potential risks in the care environment. They did not always make sure equipment and facilities supported the delivery of safe care. For example, we checked the emergency equipment and found that the adult pulse oximeter did not work. It was replaced immediately by a clinical member of staff. We found 2 open windows on the first floor that a child could have fallen through. The day after our assessment the provider sent us photographic evidence that retainers had been fitted to these windows. Cords to blinds were not secured to the wall in the 4 rooms we looked in, in line with a central alerting system (CAS) alert. The day after our assessment the provider sent us photographic evidence that all cords had been secured to the walls. A legionella risk assessment had not been completed since 2015 and this was under the previous provider. Immediately following our assessment, the provider sent us evidence the risk assessment had been booked for 15 April 2025 and that the provider’s estates department had carried out their own assessment to identify potential risks. However, a fire risk assessment had been completed and an action plan was in place to address the actions required. Medical equipment had been calibrated and appropriate service checks for domestic services and the lift were in place.

The service made sure there were enough qualified, skilled and experienced staff, who received support and appropriate training. There were a range of clinical and non-clinical roles within the practice. There was a very strong and innovative culture of developing staff to promote their development and meet the needs of the practice. For example, fellowships for GPs to specialise in areas such as dermatology, respiratory medicine, population health and musculoskeletal problems. Practice nurses had been supported to attend courses to enable them to become non-medical prescribers. Non-clinical staff had been supported to develop champion roles and undertake apprenticeships. For example, the carer’s champion was being supported to undertake an apprenticeship in project management to support them to develop their role. We found training was up to date, learning needs and development of staff was managed appropriately, and staff were working within their agreed areas of competence. There was a clear and appropriate approach for supporting and managing staff when their performance was poor or variable. Safe recruitment practices were followed.

The service assessed and managed the risk of infection. There were designated infection, prevention and control (IPC) leads and all staff were aware of who to go to for support. Staff had received appropriate IPC training. Cleaning schedules were in place and followed. Practice nurses had their own cleaning schedules to ensure equipment and clinical rooms were cleaned appropriately. Risk assessments and IPC audits had been completed and action plans put in place were required. Actions to mitigate most of the risks identified had been completed. For example, cleaning schedules, sinks and dispensers. There were still some areas on the action plan that were waiting to be addressed such as paint peeling off a handrail and a non-wipeable chair in a clinical room. Staff vaccination was maintained in line with current UK Health and Security Agency (UKHSA) guidance if relevant to their role.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Vaccines were stored and handled appropriately and staff were aware of how to maintain the cold chain including when they provided home visits to provide immunisations. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and vaccines. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments. People were involved in planning, including when changes happened. Staff followed protocols to ensure they prescribed all medicines safely, and ensured people received all recommended medicine reviews and monitoring. There were highly effective systems to manage people prescribed medicines that required monitoring and medicine safety alerts and recalls. Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. Feedback from a care home where the practice provided care and treatment was very positive about the handling of repeat prescriptions and prescribing of anticipatory medicines for people receiving end of life care.

However, the emergency medicines stock did not include all of the recommended medicines and risk assessments were not in place to mitigate potential risks. In particular, medicines used in the treatment of vomiting, pain or seizures in adults. Following our assessment the provider forwarded evidence that medicines for vomiting and seizures had been ordered and a risk assessment for lack of pain relief had been completed to mitigate potential risks. Oversight of the nurse prescribers prescribing by the provider was not in place. The day after the assessment the provider forwarded to us an updated policy to include audit and at least annual clinical supervision. Systems to track prescription stationery throughout the practice were not effective. The day after our assessment, the provider informed us of the changes they had made to rectify this. Nurses had the appropriate authorisations to administer medicines however, up to date Patient Specific Directions (PSDs) for Health Care Assistants to deliver vitamin B12 injections were not always up to date. Immediately after our assessment the provider sent us evidence that a pop up alert had been added to the records of people with a PSD in place to remind staff they must be renewed annually. They also completed an audit of all the people with a PSD in place to identify any that needed to be reviewed. Their audit identified the need to complete this audit on an annual basis.