During an assessment under our new approach
Date of Assessment: 3 to 4 March 2026. Causeway Green Surgery is a GP practice and delivers service to 3583 patients under a contract held with NHS England. The National General Practice Profiles states that 61.83% of patients are White, 21.41% Asian, 8.24% Black, 4.88% Mixed and 3.63% Other. Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the 2nd decile (2 of 10). The lower the decile, the more deprived the practice population is relative to others. This assessment considered the demographics of the people using the service, the context the service was working within and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report.
SAFE: The service had a good learning culture and people could raise concerns. Managers investigated incidents thoroughly and processes were in place to ensure learning was shared with all the team to mitigate future risks. People were protected and kept safe. Staff understood and managed risks. The facilities and equipment met the needs of people, were clean and well-maintained and any risks mitigated. Effective processes for the recruitment of staff were in place to ensure all the appropriate checks had been completed prior to commencing employment. There were enough staff with the right skills, qualifications and experience. Managers made sure staff received training and regular appraisals to maintain high-quality care. Staff managed medicines well and involved people in planning any changes.
EFFECTIVE: People were involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. Care was based on latest evidence and good practice. 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.
CARING: People were treated with kindness and compassion. Staff protected their privacy and dignity. They treated them as individuals and supported their preferences. People had choice in their care and treatment. The service supported staff wellbeing.
RESPONSIVE: The service provided information people could understand. People knew how to give feedback and were confident the service took it seriously and acted on it. The service was easy to access and worked to eliminate discrimination. Feedback from patients was positive about accessing the services provided and this was also reflected in the results of the GP National Patient Survey. People received fair and equal care and treatment. The service worked to reduce health and care inequalities through training and feedback. People were involved in planning their care and understood options around choosing to withdraw or not receive care.
WELL-LED: Leaders and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible, knowledgeable and supportive, helping staff develop in their roles. There were effective governance processes and systems in place to identify, manage and mitigate risks. Staff felt supported to give feedback and were treated equally, free from bullying or harassment. Staff understood their roles and responsibilities. Managers worked with the local community to deliver the best possible care and were receptive to new ideas. There was a culture of continuous improvement with staff given time and resources to try new ideas.