28 November 2023
During a routine inspection
We carried out an announced comprehensive at Brookvale Practice on 20 and 28 November 2023. Overall, the practice is rated as good.
Safe - good
Effective - good
Caring - good
Responsive - requires improvement
Well-led - good
Following our previous inspection on 08 September 2015, the practice was rated outstanding overall and for the effective, caring and responsive key questions and good for the safe and well-led key questions. At the last inspection we rated the practice as outstanding for providing effective, caring and responsive services because of the range of strategies that were in place to promote patient health and well-being.
At this inspection, we found that those areas previously regarded as outstanding practice were now embedded throughout the majority of GP practices. While the provider had maintained this good practice in a number of areas, the threshold to achieve an outstanding rating had not been reached. The practice is therefore now rated good for providing safe, effective, caring and well-led services. The provider is rated as requires improvement for responsive services due to the low satisfaction patients had with access to the service as indicated in the National GP Patient Survey.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Brookvale Practice on our website at www.cqc.org.uk
Why we carried out this inspection
We carried out this inspection in line with CQC methodology as the practice had not been inspected since 2015.
How we carried out the inspection
This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.
This included:
- Conducting staff interviews using video conferencing.
- Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
- Reviewing patient records to identify issues and clarify actions taken by the provider.
- Requesting evidence from the provider.
- A short site visit.
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 found that:
- Safe practices were in operation in a number of areas including staff recruitment, the maintenance of the premises and infection prevention and control.
- The provider worked with external professionals to support the health and welfare of patients.
- The provider had acted on patient feedback to improve patient’s experiences of using the service.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
We found elements of outstanding practice:-
- The provider proactively identified patients with health conditions so that these patients could access care and treatment and actively promoted health screening and flu vaccination to encourage uptake.
We rated the practice as requires improvement for providing responsive services because:-
- Although, the provider was monitoring access to appointments and had made changes to improve access. At present the National GP Patient Survey data did not indicate that these changes had been effective.
We also found that the provider should:
- Make a record of the emergency medication risk assessment so that it can be easily reviewed.
- Take action to review and improve the processes for monitoring of high-risk medicines and advising patients promptly about patient safety alerts.
- Record the monitoring undertaken of the referrals and consultations of staff employed in advanced clinical practice.
- Take action to improve the oversight of staff involved in long term condition monitoring.
- Improve the protocol for the management of hypertension to demonstrate the remit of different levels of staff involved in monitoring and review.
- Continue to monitor and improve the uptake of cervical screening and childhood immunisations.
- Take action to improve patient satisfaction in relation to access by phone and the appointment system.
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA
Chief Inspector of Health Care