Newbury Street Practice

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Patients’ medicine reviews were not always completed as required by national guidance. We found the learning from previous inspections were not always applied, and care was not provided in a way that kept patients safe and mitigated from risk of avoidable harm. Whilst some improvements had been made in relation to the safe provision of services since our last inspection, we found new concerns that had not been identified by the provider’s own quality assurance. At this assessment we found enough improvements had not been made, and there was a continued breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Patient care was not always provided in a way that kept them safe or from the risk of avoidable harm. We found learning from previous inspections was applied and improvements were made in some areas but not all. The evidence demonstrated that patients with long term conditions had not received routine monitoring tests, and diagnoses were not always recorded accurately.

Interviews with leaders demonstrated learning from significant events was identified and embedded. We found that not all the findings from our previous inspections had been acted on appropriately. The review of patient clinical records demonstrated there were improvements needed to ensure patients received the appropriate monitoring, assessment and interventions related to their care needs.

We saw evidence that learning from significant events was reported and appropriately disseminated. However, the provider’s quality systems were not always effective to ensure a good governance of the clinical records. There weren’t effective systems and processes to ensure the safe care and treatment for patients was consistently followed such as the process to carry out medicine reviews or the monitoring of patients with potential and recognised long-term conditions.

Patients’ feedback demonstrated there was continuity of care, including when people moved between different services. However safe systems of care were not always maintained therefore people's safety was not always monitored and assured.

Interviews with clinical leaders demonstrated that clinicians made appropriate and timely referrals in line with protocols and up to date evidence-based guidance.

The practice adjusted their services in response to the feedback received from the local stakeholders. Commissioners and other stakeholders told us they were able to have an open dialogue with the practice and felt that their views were respected.

We saw evidence the service offered information and flexibility, so patients were able to make informed choices about their treatments and continuity of care was reflected in the services provided.

We were told the practice worked with other agencies to support patients and protect them from risk of neglect and abuse. Emerging safeguarding risks were discussed with the safeguarding lead and relevant clinicians. Discussions with staff showed they had an understanding and awareness of key safeguarding policies.

Safeguarding policies and procedures were available and accessible to all staff. There were regular discussions between the practice and other health and social care professionals such as health visitors, school nurses, community midwives and social workers to support and protect adults and children at risk of significant harm. We found safeguarding training was provided at appropriate level for all clinical staff

Staff were aware of potential red flag symptoms and knew when to notify a GP or other clinicians with concerns about a patient who may be acutely unwell or deteriorating.

The provider had a business continuity plan in place to provide advice and guidance to staff to avoid disruption to the running of the practice. We were told there was a documented approach to the management of test results, and this was managed in a timely manner.

The practice was equipped to respond to medical emergencies and staff were suitably trained in emergency. All staff had completed basic life support, health and safety and fire training. Patient’s needs were discussed during consultations. Where patient needed additional support such as a chaperone or information in accessible way that was organised. The practice had a system for processing information relating to new patients including the summarising of new patient notes

Interviews with staff and leaders demonstrated health and safety risk assessments had been carried out and appropriate actions taken.

The practice had a range of risk assessments in place. Medical equipment was calibrated, and portable appliance testing had been undertaken to ensure equipment were fit for purpose and were in good working order.

Poor patient feedback about access as identified at our previous inspection was acknowledged and the practice has been making efforts to improve the access for their patients.

Staff told us they were encouraged to learn and develop. We saw evidence that all staff had completed all of their mandatory trainings.

There were processes for staff to have regular appraisals, one to one meetings and clinical supervision. The staff were also supported to meet the requirements of professional revalidation and were given protected time for learning and development.

The premises were visually clean, hygienic and uncluttered. Cleaning logs were maintained to evidence the cleaning carried out.

Policies and procedures were available to staff which provided guidance and information on infection prevention and control (IPC) practices. Staff had completed the infection prevention and control training relevant to their role. The practice had acted on any issues identified in infection prevention and control audits.

Patients with long-term conditions were not always reviewed to ensure their treatment was optimised in line with national guidance.

The senior leaders were not able to demonstrate effective oversight of monitoring patients’ health in relation to the use of required monitoring of prescribed medicines. The practice had a written protocol for repeat prescribing of medicines which specified the monitoring needed. However, the leaders did not have an effective system to check that prescribers were following the protocol.

We observed that prescription stationery was not appropriately controlled or recorded, and neither was it kept securely in line with national guidance and in a way that prevented its unauthorised access or use. Therefore, it was not possible to determine if prescriptions had been misappropriated. We raised this with the provider, and it was immediately rectified. The practice had a system for inviting patients for monitoring and review of their medicines. However, there did not appear to be a consistent system followed when patients did not book or attend their appointment. We reviewed the records for patients who had not had a review but had still received the regular prescription for their medicines and found significant risks to a proportion of these patients.

Care and treatment did not always reflect prescribing standards and best practice. Records we reviewed showed a number of patients had not received required monitoring or appropriate follow up, in line with current evidence-based guidance