Background to this inspection
Updated
15 September 2023
Broadway Surgery is located in Brighton at:
179 Whitehawk Road,
Brighton,
East Sussex,
BN2 5FL
The Broadway Surgery is in the Whitehawk area of Brighton. The service is provided in a purpose-built health centre on the ground and first floors. The building contains another GP practice and a pharmacy. The local area is mostly residential with a school and other health and social care services nearby.
The provider is registered with CQC to deliver the regulated activities; diagnostic and screening procedures, family planning, maternity and midwifery services, surgical procedures and treatment of disease, disorder or injury.
The practice is situated within the Sussex Health and Care Integrated Care System (ICS) and delivers General Medical Services (GMS) to a patient population of about 2350 patients. This is part of a contract held with NHS England.
The practice is part of a wider network of local GP practices who work collaboratively to provide primary care services.
There are higher than average number of patients under the age of 18, and fewer patients aged over 65 than the national average. Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the lowest decile (1 of 10). The lower the decile, the more deprived the practice population is relative to others.
According to the latest available data, the ethnic make-up of the practice area is 88% White, 5% Asian, 4% Mixed, 2% Black and 1% Other.
The practice has one full time GP and one full time practice nurse. There is one regular locum GP providing 1 session a week and a part time healthcare assistant and phlebotomist. There is a part-time practice manager and a small team of administrative staff.
The practice is open between 8am to 6.30pm Monday to Friday. The practice offers a range of appointment types including book on the day, telephone consultations and advance appointments.
Extended access is provided locally where late evening and weekend appointments are available. Out of hours services are provided by NHS 111.
Updated
15 September 2023
We carried out an announced comprehensive at Broadway Surgery on 30 May and 6 June 2023. Overall, the practice is rated as requires improvement.
Safe - requires improvement
Effective - requires improvement
Caring - good
Responsive – good
Well-led – requires improvement
Following our previous inspection on 27 May 2021, the practice was rated good overall and for all key questions.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Broadway Surgery on our website at www.cqc.org.uk
Why we carried out this inspection
We carried out this inspection in response to concerns reported to us.
Our inspection included all key questions; are services safe, effective, caring, responsive and well-led?
How we carried out the inspection
This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.
This included:
- Conducting staff interviews in person and using telephone and video conferencing.
- Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
- Reviewing patient records to identify issues and clarify actions taken by the provider.
- Requesting evidence from the provider.
- A site visit.
Our findings
We based our judgement of the quality of care at this service on a combination of:
- what we found when we inspected
- information from our ongoing monitoring of data about services and
- information from the provider, patients, the public and other organisations.
We found that:
- 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 referrrals, 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.
We 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.
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA
Chief Inspector of Health Care