The Care Quality Commission
  • Doctor
  • GP practice

The Broadway Surgery

Overall: Requires improvement read more about inspection ratings

179 Whitehawk Road, Brighton, East Sussex, BN2 5FL (01273) 600888

Provided and run by:
Dr Anita Rajda Bolczyk

Important: The provider of this service changed - see old profile

All Inspections

6 June 2023

During a routine inspection

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

27 May 2021

During an inspection looking at part of the service

We carried out an announced comprehensive inspection of The Broadway Surgery on 23 April 2019. We identified a breach of regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and issued a requirement notice. The service was rated as requires improvement for providing safe services. It was rated as good overall and good for providing effective, caring, responsive and well led services. All the population groups were rated good.

We carried out this inspection of The Broadway Surgery to confirm that the service now met the legal requirements of the regulation and to ensure enough improvements had been made.

As a result of this inspection, the service is now rated as good overall and good for providing safe services.

Throughout the COVID-19 pandemic CQC has continued to regulate and respond to risk. However, considering the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Speaking with staff in person.
  • Requesting documentary evidence from the provider.
  • A short site visit.
  • Reviewing a small sample of patient records.

We carried out an announced site visit to the service on 21 May 2021. Prior to our visit we requested documentary evidence electronically from the provider.

At the last inspection we rated the practice as requires improvement for providing safe services because:

  • Whilst the practice had systems for the appropriate and safe management of medicines, patient specific directions were not properly authorised in advance of the administration to patients (a patient specific direction is an instruction to administer a medicine to a list of individually named patients where each patient on the list has been individually assessed by that prescriber).

We also identified areas where the provider should make improvements. They were:

  • To improve the uptake of childhood immunisations.
  • To reduce the prescribing of certain medicines in line with national and local guidelines.
  • Review exception reporting and take action to improve this.

At this inspection we saw that the practice had made enough improvements, which included:

  • The development and effective implementation of a clear policy for patient specific directions which was in line with legal requirements.
  • CQC data showed an upward trend in the uptake of childhood immunisations as well as a reduction in the prescribing of certain medicines in line with recommended practice. It also showed that exception reporting rates had reduced and were now below the threshold. This was a result of a pro-active, opportunistic and personal approach taken by the practice.

We identified one area where the practice should make improvements:

  • Maintain an overview of all nurse training to ensure nursing staff are up to date with all the competencies required for their role.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

23 April 2019

During a routine inspection

We carried out an announced comprehensive inspection at The Broadway Surgery on 23 April 2019 as part of our inspection programme.

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 have rated this practice as good overall and good for all population groups, it requires improvement for the provision of safe services.

We found that:

  • The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
  • Patients received effective care and treatment that met their needs.
  • The practice monitored performance around patient outcomes and were in line with national and local averages in most areas.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way and the practice had a good understanding of the needs of the local community.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
  • There was evidence of quality improvements processes in place.
  • Staff were positive about working in the practice and were supported in their roles.
  • The practice had systems for the appropriate and safe use of medicines, including medicines optimisation, with the exception of patient specific directions which were not properly authorised in advance of the administration of medicines.
  • The practice did not achieve the target for the uptake of childhood immunisations, however they had acted to improve this.

We identified an area of outstanding practice;

  • There were examples of innovative working to engage with patients and the local community. This included a ‘worry tree’ café for both registered patient and other members of the community, improved access to services for patients with dementia, and support for vulnerable patients in the community to identify needs and provide home safety checks via the local fire service.

The area where the provider must make improvements as they are in breach of regulations are:

  • Provide safe care and treatment.

In addition, the provider should:

  • Continue to work to improve uptake of childhood immunisations.
  • Continue to work to reduce hypnotic prescribing.
  • Review exception reporting and take action to improve this.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care