The Care Quality Commission
  • Doctor
  • GP practice

Brockworth Surgery

Overall: Good read more about inspection ratings

The Surgery, Abbotswood Road, Brockworth, Gloucester, Gloucestershire, GL3 4PE 0844 477 3589

Provided and run by:
Brockworth Surgery

All Inspections

12 October 2021

During an inspection looking at part of the service

We carried out an announced inspection at Brocksworth Surgery on 12 October 2021. Overall, the practice is rated as Good.

Safe - Good

Effective - Good

Well-led – Good

At our previous inspection on 14 January 2020 the practice was rated Requires Improvement overall and for the Safe, Effective and Well-Led key questions. The key questions Caring and Responsive were rated as Good.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Brockworth Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

This was a follow-up inspection, incorporating remote searches and interviews of staff and a site visit to follow up on:

  • Key questions inspected were Safe, Effective and Well-led
  • Areas followed up including any breaches of regulations or ‘shoulds’ identified in previous inspection
  • Ratings for Caring and Responsive were carried forward from previous inspection.

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 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 short site visit
  • Obtaining feedback from other stakeholders.

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 and Good for all the population groups.

We found that:

  • Improvements had been implemented and were now embedded in practice demonstrating effective governance and assurance of essential quality standards being met.
  • The practice provided care in a way that kept patients safe and protected from avoidable harm. Examples included adherence to recruitment procedures, and the scheduled review of policies and procedures.
  • Patients received effective care and treatment that met their needs.
  • Women eligible for cervical screening were offered additional support and information to increase uptake. Unpublished data showed the practice was on track to improve uptake figures from the previous year.
  • The personal adjustments system was implemented since the last inspection, which we found was applied appropriately and based on clinical judgement of a patient’s needs.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way and survey data was consistently positive since the last inspection.
  • There was a positive culture, comprising of a cohesive and experienced team of staff.
  • The way the practice was led and managed promoted the delivery of a high-quality, person-centre care. Processes to manage and mitigate risks were improved.
  • Quality improvement initiatives such as non-clinical and clinical audits were carried out at the practice and findings were shared. The practice provided leadership on some locality wide improvement initiatives, for example, to promote healthy living.

The areas where the provider should make improvements are:

  • Continue to increase uptake of cervical screening of eligible female patients.
  • Review patients on high risk medicines to provide assurance of effective frequency and monitoring in line with national guidelines during the COVID 19 pandemic.

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

14 Jan 2020, 10 Feb 2020

During an inspection looking at part of the service

We carried out an inspection of this service on 14 January 2020 following our annual review of the information available to us including information provided by the practice. Our review indicated that there may have been a significant change (either deterioration or improvement) to the quality of care provided since the last inspection.

This inspection focused on the following key questions:

  • Is the service effective?
  • Is the service responsive?
  • Is the service well led?

We carried out a second visit on 10 February 2020 to focus on the following key questions:

  • Is the service safe?
  • Is the service caring?

We have rated the practice as requires improvement overall.

We have rated the practice as requires improvement for providing safe, effective and well led services because:

  • Processes to monitor and mitigate risk were not always effective.
  • Oversight of significant event processes was not embedded.
  • The practice had not identified ways to improve areas of high exception reporting to support positive patient outcomes.
  • Policies were not always fully comprehensive or in line with national guidance.
  • Systems did not always support effective governance oversight.
  • Recruitment processes were not embedded.

These areas affected all population groups so we rated all population groups as requires improvement.

We have rated the practice as good for providing caring and responsive services because:

  • The practice organised and delivered services to meet patients’ needs.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.

The areas where the provider must make improvements are:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

  • Identify ways to improve uptake for cervical screening.
  • Identify ways to improve patient satisfaction in relation to appointment times.

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

Rosie Benneyworth

Chief Inspector of PMS and Integrated Care

9 June 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Brockworth Surgery on 9 June 2016. Overall the practice is rated as good.

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

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients were assessed and well managed.
  • Staff assessed patients’ needs and delivered care in line with current evidence-based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • The patient participation group was well engaged, and had suggested a number of changes to the practice management team which had been acted upon.
  • 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 and complied with the requirements of the Duty of Candour.

When there were unintended or unexpected safety incidents, patients received reasonable support, truthful information, a verbal and written apology and were told about any actions to improve processes to prevent the same thing happening again.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

11 October 2013

During a routine inspection

During this announced visit, we spoke to one person who used the service. We spoke to the chair and vice chair of the patient participation group (PPG). We spoke to staff, observed interactions in the reception area and looked at documents held by the provider.

Staff, the patient we spoke to and the PPG all confirmed that people who used the service were always involved in their care and treatment. We observed interactions between the reception staff and people who used the service. We found this to be respectful for people's individual needs and friendly. The practice had good safeguarding procedures in place for both adult and children. They also had good systems in place for medicines management. The practice had an established and effective patient participation group and we spoke to the chair and vice chair. They told us 'we feel the staff are always open and transparent with us, they listen to what patients are saying and they are honest when they can't change things'.

Patients were offered the chance to talk to us when they arrived at the surgery. Only one person wanted to talk to us during our visit. They told us 'I have received very good treatment, the doctors are excellent'. We saw other positive comments from the feedback forms including "Always friendly and helpful whilst being professional, one of the best surgeries we have been registered with" and "I would like to praise the doctor, very helpful"