The Broadway Surgery

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that the service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted open, fair culture.

At our last assessment, we found the service did not have effective governance systems in place to support the delivery of services. Leaders lacked oversight and processes did not operate as intended. At this assessment, we saw improvements had been made.

At our last assessment, we rated this key questions 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.

Staff told us they cared about their work and were committed to getting it right. They respected the partners and told us they are accessible to speak to and obtain guidance from. Staff told us most discussions were held informally and as situations arose to ensure timely actions. Staff told us they felt able and supported to raise questions or concerns with the management team.

People told us they had a positive experience of the practice. For example, 73% of respondents of the national GP patient survey 2024 found the service to be very good or fairly good.

There were established and effective systems in place to promote adherence to the values of the organisation. There were appraisal processes in place for clinical and non-clinical staff. Individual and collective performance was consistently monitored by the leadership team.

Systems and processes were always defined and adhered to by leaders .

The leaders demonstrated that they had the capacity and capability to ensure that the organisational vision could be delivered. They identified and managed risks. They did so with integrity, openness and honesty.

Staff told us leaders in the practice were approachable and responded to any concerns raised. Staff also told us leaders modelled the values of the practice. We saw the leadership team worked with other practices in the primary care network and were engaged in the development of primary care services in the local area.

Staff told us their management team and colleagues acted with openness, honesty and transparency in the dealings with one another and people. Staff told us they were trusted to work with autonomy but had the support of the management team.

The practice had a nominated speak up champion for staff to approach if they felt unable to directly raise concerns with the management team. Staff also had access to external speak up champions if they felt more comfortable to do so. Concerns raised by staff informally and formally were all recorded, investigated and responded to and any learning identified and shared to drive improvements.

Staff told us they valued their colleagues and the opportunities to support one another, shared learning and diversify their knowledge and skills base. Staff felt confident raising concerns or questions and welcomed the support of the Integrated Care Board (areNHS organisations responsible for planning and commissioning health services for their local population).

There were established, effective and inclusive systems and processes in place to demonstrate the leaders had reviewed, considered and improved the culture of the practice. The management team sought staff views and opinions directly. Reasonable adjustments had been made in response to health and safety considerations.

The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

The service conducted checks on individuals and collective performance to ensure adherence to safe practice. Significant events were investigated and learning identified to prevent recurrence. Concerns raised in clinical meetings were actioned and resolved.

Leaders and leaders supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Leaders met with staff regularly to complete appraisals and performance reviews. The service had established governance processes that were appropriate for their service. Staff could access all required policies and procedures. Leaders held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks. Leaders clearly recorded any actions arising from these meetings and ensured they shared these with staff. Staff took patient confidentiality and information security seriously.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

The service worked with other practices within their primary care network to offer extended access, and flu and covid vaccination programmes. Staff had made adjustments to improve coordination of their service with community healthcare services, including through recently established weekly meetings centred on the care of those at higher risk of hospital admission.

The service understood the importance of continuously learning and developing. They invested time and resources into listening to people’s experiences and made changes to improve the service. They referred to their patient participation group (PPG) as critical friends and valued their experiences and contribution to improving the service. We saw minutes of meetings held with the PPG which demonstrated good communication and information sharing, including new services available at the local hub.

There were established systems and processes to ensure staff learnt from previous adverse incidents. Encouraging an understanding of risks, strengthened operating systems and improving people’s skills and knowledge, to prevent the risks from reoccurring.