Newbury Street Practice

We carried out an announced focused inspection at Newbury Street Practice on 20 September 2022. Overall, the provider is rated as inadequate.

We rated the following key questions as:

Safe - Inadequate

Effective - Inadequate

Caring - Good (rating carried forward from previous 2016 inspection)

Responsive - Good (rating carried forward from previous 2016 inspection)

Well-led - Requires improvement

Following our previous inspection in October 2016 the provider was rated good for all key questions.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Newbury Street Practice on our website at www.cqc.org.uk

Why we carried out this inspection

We undertook this inspection as part of a random selection of services rated Good and Outstanding to test the reliability of our new monitoring approach.

This was a focused inspection which included the key questions safe, effective and well-led and specific questions from responsive to find out whether patients could access services effectively and in a timely manner.

How we carried out the inspection:

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account 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:

• Conducting staff interviews using video conferencing facilities.
• Completing clinical searches on the provider’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 short 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 have rated this provider inadequate for providing safe services because:

• Safe recruitment checks were not always carried out in line with provider policies.
• Staff immunisations were not monitored.
• Infection Prevention and Control audits were not carried out fully or acted upon.
• Infection Prevention and Control routine tasks were not completed in line with provider policies.
• There was no clear timeline for when the backlog in summarising patient records will be completed.
• There were gaps in the process for monitoring repeat medicines and structured medicines reviews.
• The system for managing and acting on Medicines and Healthcare products Regulatory Agency (MHRA) safety alerts was not always effective.

We have rated this provider inadequate for providing effective services. This is because:

• Patients were not always regularly reviewed and updated in line with current guidance.
• The provider was not able to demonstrate they always obtained and recorded consent or carried out assessments on a patient’s capacity to consent.

We have rated this provider requires improvement for providing well-led services. This is because:

• The overall governance structures in place were not always effective.
• The process for managing risks needed to be strengthened.
• The provider did not have systems in place to continue to deliver services, respond to risk and meet patients’ needs during the pandemic.

We also found that:

• Staff dealt with patients with kindness and respect.
• The provider had a strong focus on person centred care and preferred all patients to see their usual GP for continuity of care.
• There was a programme of quality improvement initiatives and a culture of continuous learning.
• The provider adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
• The provider recognised the importance of their Patient Participation Group and acted on suggestions.
• Leaders were approachable.
• Staff were supported to develop and progress within the provider if they wanted to.
• The provider was involved in some innovative projects and pilot schemes. For example, the provider website had a ‘lifestyle medicine’ section made up of short videos advising patients on how to make better lifestyle choices.
• The provider had worked with a local secondary school to look at the needs of young people and improve their access to services at the provider.

We found three breaches of regulations. The provider must:

• Ensure care and treatment is provided is a safe way to patients.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Ensure where appropriate, persons employed are registered with the relevant professional body.

In addition, the provider should:

• Improve the staff awareness of the Freedom to Speak Up Guardian.
• Improve the recording and sharing of information following a significant event.

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

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement, we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services