The Broadway Surgery

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

At our last assessment, we found that the practice did not always provide care in a way that kept people safe and protected them from avoidable harm. We previously identified concerns relating to medicines management; health and safety; and how incidents were recorded and acted on.

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.

Staff knew how to raise concerns and told us they were supported to do so. Staff were able to provide us with examples of learning from incidents. We saw examples of complaints investigated; discussions held and follow on actions to resolve. They believed leaders and colleagues were committed to investigating, resolving and learning from incidents. Where improvements were required, information, advice and guidance were shared verbally amongst staff to improve the safety and standards of care.

There were established and effective formal and informal systems in place to capture concerns from people, staff, and partner services. Incidents and complaints were investigated in a timely and appropriate manner. Honest and transparent accounts were provided to people and where appropriate lessons learnt and shared to improve the service.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. There were systems in place for processing information relating to new people. The service worked with people and healthcare partners to deliver shared care and when people moved between services. Referrals and test results were managed in a timely way.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

The service had established and effective systems in place to safeguard vulnerable adults and children. Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations. Records of vulnerable people were regularly revised to ensure information was current and relevant. We saw children had been appropriately followed up with when they failed to attend appointments with primary and secondary care services. This was overseen by an appointed safeguarding lead who contributed to multidisciplinary meetings.

We checked a sample of records for people and found appropriate safeguards had been observed.

There were established and effective processes in place to support the early recognition and timely response to risks. Staff told us they invested in getting to know their people so they could help understand and support them to manage their health.

People told us they were involved in decisions relating to their care. They were supported to identify and respond to changes in their health and signposted to support services appropriate to their personal care.

Emergency equipment was available and maintained. Staff could recognise a deteriorating patient and knew of action to take. People were advised on risks related to their condition and actions to take if their condition deteriorated.

Staff told us they had undertaken annual training in health and safety and practice procedures. Clinical staff had been trained in emergency first aid. Staff could alert colleagues to concerns such as verbal or physical abuse using their clinical system and this was regularly tested.

The property was managed by an external company and the service had liaised with them since the last assessment to arrange for access to all monitoring and risk assessment documentation for the property.

There were established and effective systems in place to identify, manage and mitigate risks to people. People had access to chairs with arms in the waiting areas to assist those with limited mobility. There were appropriate child changing facilities with appropriate restraint belt to mitigate the risk of the child falling whilst being changed. Clinical staff used single use items and had access to body fluid spillage kits to mitigate the risk of infection to people. We saw fire safety wardens were on duty and all staff were aware of evacuation procedures and fire drills had been completed.

The service had conducted environmental risk assessments (including legionella testing and portable appliance testing) to ensure staff and people were safe. There were reviewed annually or more frequently in response to changes.

Maintenance contracts were in placed to maintain the accuracy of equipment (calibration), scheduled safety checks were conducted on the fire alarm system, emergency lighting and equipment. Staff had undergone Disclosure and Barring Service checks (a way for employers check your criminal record, to help decide whether you are a suitable person to work for them) or risk assessed.

Information was displayed throughout the building and on the services website promoting dignity and respect to people and the standards of conduct expected.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Staff and leaders understood the recruitment, disciplinary and capability processes and believed they were fair. Leaders ensured they were applied appropriately to ensure there is no disadvantage based on any specific protected equality characteristic. Clinical staff maintained their professional revalidation, and staff were working in their agreed areas of competence.

We found safe recruitment practices were followed when appointing clinical and non-clinical staff, including locum staff. We found training was up to date, learning needs and development of staff was managed appropriately, and staff were working in their agreed areas of competence. Clinical staff maintained their professional revalidation. Thereby, providing greater assurance to people, employers and other healthcare professionals that licensed clinicians are up-to-date and fit to practice. Previously we found that staff training was not up to date and there wasn’t evidence to show appropriate checks for locum staff were always completed. At this assessment we saw that improvements had been made.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service had a designated infection prevention and control lead and all staff had completed relevant training. Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks. We saw evidence that damage to furniture that was repaired or replaced. The infection prevention and control (IPC) risk assessment was carried out in January 2025. All areas requiring action had been completed. For example, a specimen bin had been replaced with one with a secure lid.

The service made sure medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened. The service had made necessary improvements in monitoring high-risk medicines. Our remote clinical searches identified 41 out of 52 people prescribed anticoagulants had received appropriate monitoring. (Anticoagulants are medicines that prevent blood clots forming). Immediately following the assessment, the service arranged for the outstanding 12 people be encouraged to attend a review appointment.

The service had effective systems to manage and respond to safety alerts and medicine recalls. We reviewed people prescribed teratogenic medicines in line with a medicines alert. (These are medicines that can cause birth defects or functional damage to a developing foetus or child when a pregnant person is exposed to them). We found appropriate steps had been taken to monitor and communicate with people so they could make informed decisions about their care. There was a programme of regular clinical audits of prescribing that focused on improving care and treatment.

People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms. Staff managed prescription stationery appropriately and securely. Staff stored medical gases, such as oxygen, safely and completed required safety risk assessments.

People were signposted to additional support services to help them with their condition. For example, dietary advice or smoking cessation.