Baddeley Green 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

People were involved in assessments of their needs. Staff completed assessments taking account of people’s communication, personal and health needs. Care was based on latest evidence and good practice. However, our clinical searches found some gaps, for example in the provision of patient information sharing such as steroid cards, the documentation of contraceptive advice, the provision of an electrocardiogram (ECG) for those on a specific medicine and electronic coding. The provider following this feedback provided evidence of their appropriate and prompt actions. Staff worked with all agencies involved in people’s care for the best outcomes and smooth transitions when moving services. Staff made sure people understood their care and treatment to enable them to give informed consent. Staff involved those important to people and took decisions in people’s best interests where they did not have capacity.

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.

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. Reception staff were aware of the needs of the local community. Reception staff used digital flags within the care records system to highlight any specific individual needs, such as the requirement for longer appointments or due to mobility to not have an appointment at the annex on site which had stairs to navigate.

We reviewed the records of 3 out of 33 patients who had received 2 or more courses of rescue steroids to treat an exacerbation of their asthma. These patients had received a follow up consultation; however not all had been in receipt of a steroid card, in line with national guidance.

Our clinical searches identified 7 patients as having a potential missed diagnosis of diabetes. We sampled 3 patient records and found the practice did not always follow the interval testing regime, but this was due to patients not attending. The provider following this feedback provided evidence of their appropriate and timely actions.

Staff checked people’s health, care, and wellbeing needs during health reviews. Clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing. The provider had effective systems to identify people with previously undiagnosed conditions. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber.

Leaders told us the service followed best practice guidance and standards. They told us that evidence based clinical templates, which were updated regularly, were used to support the care and treatment of patients.Systems were in place to ensure staff were up to date with evidence-based guidance and legislation. Our remote clinical searches showed that action had been taken in the majority of instances where required and patients had been contacted in relation to specific safety alerts.

Staff had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support. The practice worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services. End of life care was delivered in a coordinated way. The practice worked with the multi-disciplinary community support team to review the care and treatment for this group of patients. From the minutes we reviewed, we found examples where patients decisions had been supported.

The practice worked with the Primary Care Network (PCN) team and offered a range of services such as social prescribing, pharmacist, physiotherapy, occupational therapy and mental health support.

Staff focussed on identifying risks to patients’ health, including those in the last 12 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 and tackling obesity.

Staff and leaders told us they used a range of methods to support patients to live healthier lives for example, health promotion and education and national initiatives. Evidence of these methods were seen displayed on site and on the practice website. We noted for example that the social prescribers were at a local club on a weekly basis. A supporting ‘new dads’ leaflets had been developed and produced to further promote the support and information available to new fathers.

NHS Digital data to the period, 30 June 2024 found cervical screening uptake in both age range groups to be below the 80% target. Four of the childhood immunisation uptake targets were below the expected 95% target. The practice demonstrated they had an effective recall system in place and strategies to health educate and encourage attendance. In response to our feedback the provider reported that during 2024/2025 only 3 children aged 2 years were not immunised for measles, mumps and rubella, Haemophilus influenzae type b (Hib) and meningococcal group C (MenC) (Neisseria meningitidis group C). In each case, the parents had declined immunisation, and this was appropriately recorded in the clinical records.

Staff understood and applied legislation relating to consent. Capacity and consent were clearly recorded. Do Not attempt Cardiopulmonary Resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation. There were policies in place to support staff when obtaining consent from adults, children and patients that lacked mental capacity. We found that clear discussions were recorded in the patients’ electronic records regarding the decision to put a DNACPR plan in place if this had been initiated or reviewed by the practice.The practice offered a minor surgical procedures service led by the lead GP. Documented consent was in place for these procedures and appropriate audits undertaken.