Balaam Street Surgery

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We looked for evidence that staff involved people in decisions about their care and treatment and provided them advice and support. Staff regularly reviewed people’s care and worked with other services to achieve this.

This is the first inspection for this service since its registration with CQC. This key question has been rated as good.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service made sure people’s care and treatment was effective by thoroughly assessing and reviewing their health, care, wellbeing and communication needs with them. Leaders at the service had created ‘clinical decision making’ guidelines and ‘clinical assessment policies’ to assist and support staff in examining patients. These guidelines and policies were derived from published clinical guidelines and were made available to clinical staff working at the practice. The clinical assessment policies were summarised into history, examination, investigation, potential red flags and the resources available. Templates were made for consistent diagnosis and consultation.

Feedback from people using the service was positive. People felt involved in any assessment of their needs and felt confident that staff understood their individual and cultural needs. This was reflected in the 2025 GP Patient Survey, in which 88 percent of respondents stated their needs were met during their last general practice appointment. Reception staff were aware of the needs of the local community.

Requests for appointments were initially triaged and signposted by the reception staff who had received care navigation training, before passing on to the duty GP if required. Staff checked people’s health, care, and wellbeing needs during health reviews. The provider had effective systems to ensure all staff members were aware of patients’ specific needs with alerts attached on different practice databases.

Patients with learning disabilities received annual health checks. 42 out 48 patients with a learning disability had completed their annual health check; an action plan had been created to follow up on the six patients who had not responded to their annual health check-up reminders.

The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation. They worked to develop evidence-based practice and standards through clinical pathology policies, clinical decision-making guidelines and ongoing educational training.

Systems were in place to ensure staff were up to date with evidence-based guidance and legislation. Our review of the clinical record system for patients whose care and treatment we looked at, indicated that people received care, treatment and support that was in line with good practice standards. Patients living with long-term conditions were being monitored and managed appropriately.

Staff attended in-house and external meetings, training, education sessions and underwent regular appraisals. When reviewing the services clinical record system, we found that the workflow for managing clinical correspondence within the clinical record system were reviewed and up to date.

The practice worked well across teams and services to support people. The practice worked with other services to ensure continuity of care. Leaders and staff worked closely with colleagues within their local Primary Care Network (PCN). Multi-disciplinary meetings were held on a regular basis, both in-house and with other services. The practice worked with mental health practitioners with a community psychiatrist nurse working across the PCN and operated a weekly clinic at the practice.

The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduce their future needs for care and support.

Staff focused on identifying risks to patients’ health, including those in the last twelve months of their lives, patients at risk of developing a long-term condition and those with caring responsibilities. Staff supported national priorities and initiatives to improve population health, including stopping smoking, tackling obesity and alcohol dependency.

The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves. Two-cycle audits were performed to find ways they can improve the quality of patient care. For example, the practice performed an audit to improve the prescribing practices of amoxicillin, which had a positive outcome, demonstrating progress in reducing unnecessary antibiotic prescriptions.

The practice, however, did not meet national targets for cervical cancer screening and immunisations. The percentage of persons eligible for cervical screening as of 31/06/2023 who were screened was 62 percent, lower than the expected target of 80 percent. All five indicators for childhood immunisation uptake were below the ninety percent World Health Organisation target. The practice demonstrated efforts made to increase uptake for both childhood immunisations and cervical cancer screening and educated patients around the importance of immunisation. However, the practice acknowledged further recruitment to their nursing staff would assist uptake and planned to recruit another practice nurse.

From the clinical notes we reviewed, we found that people who used the service experienced positive outcomes as set out in legislation and evidence-based clinical guidance.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff understood and applied legislation relating to consent. Capacity and consent were clearly recorded. We reviewed a sample of Do not attempt cardiopulmonary resuscitation (DNACPR) decision records. Staff had completed these documents appropriately, shared them with relevant services and added alerts to the patient records system. We found relevant documentation in the care records of patients who lacked the capacity to make decisions.