We carried out an announced comprehensive inspection at Brickfields Surgery on 27 March 2019 as part of our inspection programme.

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 and good for all population groups, except for patients with long-term conditions, which we rated as requires improvement.

We rated the practice as requires improvement for providing safe services because:

• There was no evidence of staff receiving training in adult safeguarding and one clinician required refresher training in child safeguarding
• The practice provided most care in a way that kept patients safe and protected them from avoidable harm. However, evidence was lacking relating to some risk assessments and environmental audits and some training updates for both clinical and non-clinical staff.
• The process for monitoring prescription stationery did not provide assurance that monitoring was effective.
• There was no system in place to regularly check that clinical staff professional status was still valid.
• Staff did not routinely undertake training in fire safety or infection control. We found a lack of fire drills and fire marshals had not been appointed.
• Reception staff had not received recent training in the identification of patients with sepsis.

We rated the population group ‘patients with long-term conditions’ as requires improvements because:

• Performance data from the Quality and Outcomes Framework showed that improvements were required in the monitoring and review of patients with long-term conditions.

We rated the practice as good for providing effective, caring, responsive and well-led services because:

• Most patients received effective care and treatment that met their needs.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• CQC comments cards reflected that patients felt staff had a caring, respectful attitude.
• The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
• Staff felt supported and there was a staff development structure in place.
• The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

The areas where the provider must make improvements are:

• Ensure care and treatment is provided in a safe way to patients.

The areas where the provider should make improvements are:

• Review the level of documentation of discussions of complaints within meeting minutes.
• Embed and maintain the system for regularly checking the professional status of clinical staff.
• Embed and maintain the system for monitoring prescription stationery.
• Improve the outcomes for patients with long-term health conditions.
• Improve uptake rate of immunisation for measles, mumps and rubella for 2-year-old children.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care