CQC Report: The Broadway Surgery, September 2023

The Care Quality Commission (CQC) carried out an announced comprehensive inspection at the Broadway Surgery on 30 May and 6 June 2023. Overall, the practice was rated as "Requires Improvement." This was a decline in the rating following a previous inspection on 27 May 2021, when the practice was rated good overall.

To get to the heart of patients’ experiences of care and treatment, the CQC always ask the following 5 questions:

• Is it safe? Rated as Requires Improvement

• Is it effective? Rated as Requires Improvement

• Is it caring? Rates as Good

• Is it responsive to people’s needs? Rated as Good

• Is it well-led? Rated as Requires Improvement.

Summary of the findings

• The practice did not always provide care in a way that kept patients safe and protected them from avoidable harm.
• Risks to patients, staff and visitors were not always assessed, monitored or managed in an effective manner. This included medicines management, the management of safety alerts, the management of referrals, the management of patients with long term conditions, and health and safety.
• There was limited evidence to demonstrate that all incidents, concerns, complaints or near misses were consistently recorded or that opportunities for learning and quality improvement were identified.
• The responsibilities, roles and systems of accountability to support good governance and management were not always clear or effective.
• Governance systems and processes were not established and operating effectively. • Most staff told us they were happy with the level of support provided by the management team. However, feedback was mixed about the communication within the practice.
• The practice hosted or delivered additional services; including complementary therapies and exercise classes.
• Staff were caring of the needs of patients and had a clear patient focus.
• The practice engaged with the local federation and primary care network to review local services and how they worked together.

CQC found 2 breaches of regulations. The provider must:

• Ensure that care and treatment is provided in a safe way.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

Additionally, the provider should:

• Improve the uptake of cervical screening and childhood immunisations.
• Improve the process for investigating and recording outcomes from complaints, including how information is shared to ensure learning and improvement.

NHS Sussex response (January 2023)

"Following the recent inspection at Broadway Surgery, the Care Quality Commission (CQC) has identified some areas of the service that require improvement.

"CQC inspections help NHS services to identify areas of improvement to ensure they can provide a high-quality service to patients. We understand that the CQC report may cause concern and would like to reassure patients that the appropriate steps are being taken by the practice to implement improvements.

"We are confident that the practice’s top priority is patient safety, and the focus for the next six months is transforming the service to ensure the areas highlighted in the report are up to the required standard. 

"The practice is continuing to make steady improvements, by working collaboratively with members of the clinical and managerial teams of NHS Sussex and the Local Medical Council (LMC) to address the areas highlighted. An improvement plan has been submitted to CQC and is now being implemented.

"Examples of this include:

• The practice has improved their current systems and processes aimed at improving overall patient care and outcomes.
• The practice has worked alongside the Primary Care Network Pharmacy team to improve the protocols that help to ensure that all appropriate tests and treatments are ordered and that the patients’ conditions are regularly monitored.
• The practice has improved the way they manage their patients with long term conditions, by ensuring patients are invited in for annual reviews and follow up appointments as required.

"Broadway Surgery was rated ‘good’ in areas for being caring and being responsive to people’s needs. If you have any concerns or would like to speak to someone, please contact your surgery."