Newbury Street Practice

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

The service was not did not always demonstrate effective leadership and governance. There were concerns regarding clinical leadership, governance and risk management. We found systematic gaps which led to shortfalls in the delivery of patients’ care. We saw some improvements had been made in relation to the management of premises, equipment, medicines storage and management of staff and other tasks. At this assessment we found breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff felt well supported and listened to by leaders. They explained there had been an improvement in culture over the previous 12 months.

There were insufficient processes to ensure there was appropriate direction and leadership regarding aspects of clinical care. Patients with some long-term conditions were not receiving the monitoring of their care as a result.

Staff told us leaders were inclusive and supportive of staff However, leaders were not demonstrating they had the knowledge and the capabilities needed to ensure clinical care was monitored and improvements were made where necessary.

There were insufficient processes to ensure there was appropriate direction and leadership regarding all aspects of clinical care. Patients with some long-term conditions were not receiving the monitoring of their care as a result

Staff understood their responsibilities to raise concerns and knew how to report issues of concern. They understood the process for freedom to speak up. However, senior leaders had not appropriately responded to clinical risks reported on two previous CQC inspections.

There were policies and processes to enable staff to speak up and report issues in confidence if they needed to.

There was training for staff in equality diversity and human rights and these requirements were included in policies.

Senior leaders reported that there had been a successful recruitment campaign for both clinical and support staff that had improved the delegation of roles and responsibilities within the service, over the last 12 months. This had provided a greater diversity of skills and greater ability for the practice to plan the delivery of future services. However, lead clinicians were not fully aware of some shortfalls in clinical care and had not identified what requirements were needed to ensure improvements were made to services where previously reported by CQC.

Governance systems had improved over the previous 18 months, with regard to the management of premises, equipment, medicines storage and management of staff and other tasks. However, there continued to be shortfalls in the governance processes regarding clinical care and ongoing monitoring of patients’ health conditions. This posed a continued risk to the wellbeing and safety of patients.

The practice had worked with commissioners and other health providers to improve appointment access and patient pathways. They continued to engage proactively with stakeholders including their patient participation group (PPG).

The PPG spoke positively about the practice and how well they engaged with them. Commissioners reported having regular input and engagement with the practice.

There were effective processes for engaging with stakeholders and partners.

There were insufficient processes to identify areas of shortfall in clinical care and drive the improvements needed. The clinical audits shared with us did not identify appropriate quality improvement based on areas where CQC had identified gaps in clinical care. There was some learning and improvement from previous inspections which had enabled better management of non-clinical governance processes. This had improved the safety and effectiveness of the service.