We carried out an announced comprehensive inspection at Brandon Street Surgery on 13 January 2017. The overall rating for the practice was good with requires improvement for providing safe services.

From the inspection in January 2017 the practice was told they must:

• Review processes for reporting, recording, acting on and monitoring significant events, incidents and near misses. Ensure actions agreed to ensure lessons learnt following discussion of a significant event are documented with timely review dates. Ensure complete records are kept of all completed significant event report forms received including details of actions taken as a result.

In addition, the practice was told they should:

• Review processes in place in relation to clinical audits to ensure full cycle audits are carried out to improve patient outcomes.
• Review system of appraisals to ensure all members of staff receive an appraisal at least annually.
• Review complaints processes to keep a record of informal complaints received and ensure a system is in place to enable the practice to monitor trends.
• Review methods of communication and meeting structures to ensure all practice staff clinical and non-clinical are provided with the opportunity to be involved in discussions about the practice.

The full comprehensive report on the January 2017 inspection can be found by selecting the ‘all reports’ link for Brandon Street Surgery on our website at .

This inspection was an announced focused inspection carried out on 4 February 2019 to confirm that the practice had made the recommended improvements that we identified in our previous inspection on 13 January 2017. This report covers our findings in relation to those improvements made since our last inspection.

Our judgement of the quality of care at this service is based 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.

The practice is rated as good overall and good for all the population groups.

At this inspection we found:

• The practice had implemented a system to ensure that significant events were managed safely and that learning from those events was shared across the practice.
• We saw evidence that when a significant event took place, it was appropriately recorded and acted upon.
• Risks to patients were now being safely managed and mitigated.
• We saw evidence that full cycle audits had been completed since our last inspection. Further audits had been completed and we saw evidence that future audits were planned.
• A system had been implemented to ensure staff received regular appraisals and we saw evidence that appraisals had been carried out with staff since our last inspection. These appraisals covered staff training needs and any performance issues.
• Complaints received in written or verbal form were now being captured by staff in order to effectively monitor these, share learning across the practice and identify any trends and themes.
• A schedule of meetings now took place at the practice which included monthly clinical meetings, monthly nurse clinical meetings, all staff meetings and safeguarding meetings with health visiting teams when they were available. We saw meeting from these minutes and saw that significant events and complaints were discussed.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Brandon Street Surgery on 13 January 2017. Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

• Results from the national GP patient survey showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
• We found that the system for reporting and recording significant events was inconsistent and required review. We were unable to see evidence of discussion of actions taken or lessons learnt discussed or shared with the practice team. The practice did not document discussions held regarding near misses.
• Information about services and how to complain was available for patients. However, the practice did not keep a record of informal complaints received to enable the practice to identify any trends in complaints.
• Risks to patients were assessed and well managed.
• The practice had made significant improvement to Qof performance however, patient outcomes were hard to identify as little or no reference was made to audits or quality improvement with the exception of medicines management audits that had been carried out.
• Childhood immunisations were carried out in line with the national childhood vaccination programme. Uptake rates for the vaccines given to five year olds were higher than CCG/national averages.
• The practice had a proactive patient participation group and had sought feedback from patients.
• The practice had clearly defined and embedded systems to minimise risks to patient safety.
• Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
• The provider was aware of the requirements of the duty of candour.

The areas where the provider must make improvement are:

• Review processes for reporting, recording, acting on and monitoring significant events, incidents and near misses. Ensure actions agreed to ensure lessons learnt following discussion of a significant event are documented with timely review dates. Ensure complete records are kept of all completed significant event report forms received including details of actions taken as a result.

The areas where the provider should make improvement are:

• Review processes in place in relation to clinical audits to ensure full cycle audits are carried out to improve patient outcomes.
• Review system of appraisals to ensure all members of staff receive an appraisal at least annually.
• Review complaints processes to keep a record of informal complaints received and ensure a system is in place to enable the practice to monitor trends.
• Review methods of communication and meeting structures to ensure all practice staff clinical and non-clinical are provided with the opportunity to be involved in discussions about the practice.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice