The Broadway 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

At the last assessment the service was unable to demonstrate that people’s needs were adequately assessed, and care and treatment was not delivered in line with evidence based guidance.

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

At our last assessment, we rated this key question as requires improvement. At this assessment, the rating has changed.

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 assessing and reviewing their health, care, wellbeing and communication needs with them.

Feedback from people using the service was positive. People felt involved in assessments of their needs and felt confident that staff understood their individual and cultural needs.

Clinical records were appropriately coded and flagged to alert staff to individual’s needs and preferences. Vulnerable groups were proactively invited for health checks, such as carers and those with long term health conditions.

Reception staff were aware of the needs of the local community. They used digital flags in the care records system to highlight any specific individual needs, such as the requirement for longer appointments or for a translator to be present. 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 service had effective systems to identify people with previously undiagnosed conditions. For example, we reviewed patients with a potential missed diagnosis of CKD and found they had received necessary interventions.

Clinical staff received support and supervision from experienced clinicians to ensure their decisions were reflective of legislation, evidence-based good practice and required standards. Clinical records we saw demonstrated care was provided in line with current guidance.

Audits had been conducted on administrative processes such as the timeliness of cancer referrals or clinical processes such as safe prescribing.Regular discussions and formal meetings were held with staff to discuss clinical practice, risks and changes to ways of working and systems and processes for clinical referrals and review of results. For example, the clinical meeting minutes from April 2025 included improvements to their prevention of cardiovascular disease and the reduction of antibiotic prescribing.

Staff worked effectively across teams and services to support people. Staff had access to the information they needed to appropriately assess, plan and deliver people’s care, treatment and support. We found clinical records were detailed regarding assessments and contained supporting rationales for actions taken. Since the last assessment the service had put in place effective systems to ensure the timely and appropriate management of referrals. We saw evidence to confirm this.

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 focussed on identifying risks to people’ health, including those in the last 12 months of their lives, people 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. The service had collaborated with a local Reiki practitioner group who offered up to 6 free sessions to people referred by the practice. (Reiki is used to promote relaxation reduce stress and improve mood and well-being.)

Staff told us they routinely monitored people’s care, booked follow up consultations and requested additional interventions such as blood tests to continuously improve people’s health outcomes. We found pathology results were reviewed and actioned in a timely manner and people were supported to understand and manage their individual needs. There were established and effective systems in place to identify and monitor people’s outcomes. From clinical notes we reviewed, we found that people who used the service experienced positive outcomes as set out in legislation, standards, and evidence-based clinical guidance.

However, the service did not meet all national targets for screening and immunisations. Cervical screening uptake of 68% was below the national target of 80%. The service continued to encourage people to attend screening appointments.Immunisation targets were met and for 2-year olds, 100% was achieved, although the uptake for 5 year olds MMR vaccinations was below the 90% target, at 83%.

The practice had established policies and procedures in place to ensure staff knew and observed best practice when recording and delivering care. Staff understood and assessed children under 16 years using Gillick competency. Thereby able to consent to their own medical treatment, without the need for parental permission or knowledge.

Staff told us they received training in understanding and supporting people to make informed decisions. Consent was sought in accordance with best practice to ensure people had time to understand, consider and ask questions. For example, consent was appropriately obtained or documented prior to administering vaccinations to vulnerable people.

Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation.