The Care Quality Commission
  • Doctor
  • GP practice

The Broadshires Health Centre

Overall: Good read more about inspection ratings

Broadshires Way, Carterton, Oxfordshire, OX18 1JA (01993) 845600

Provided and run by:
The Broadshires Health Centre

All Inspections

28 June 2023

During an inspection looking at part of the service

We carried out an announced focused inspection at The Broadshires Health Centre from 27 to 29th June 2023. Overall, the practice is rated as good.

Safe - good

Effective - good

Responsive - good

Well-led - good

Following our previous inspection published in April 2017 we rating the practice as Good.

The full reports for previous inspections can be found by selecting the 'all reports' link for The Broadshires Health Centre on our website at www.cqc.org.uk

Why we carried out this inspection

We undertook this inspection as we were made aware of risks associated with a loss of staff and leadership team members which potentially impacted on the ability of the service to provide appropriate service standards to patients. Therefore we undertook a focused inspection including the key questions of safe, effective, 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 using 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 provided care in a way that kept patients safe and protected them from avoidable harm.
  • Patients received effective care and treatment that met their needs.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • Innovation was encouraged by leaders and staff participated in quality improvement activity.
  • Patients could access care and treatment in a timely way.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

We found no breaches of regulations. The provider should:

  • Continue to implement the revised monitoring systems for patients on repeat medicines and prescribing subject to patient safety alerts.

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

We have not revisited The Broadshires Health Centre as part of this review because they were able to demonstrate that they were meeting regulations associated with the Health and Social Care Act 2008 without the need for a visit.

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

Our previous comprehensive inspection at The Broadshires Health Centre on 26 August 2016 found a breach of regulation relating to the safe provision of services. The overall rating for the practice was good. Specifically, we found the practice to require improvement for provision of safe services. It was good for providing effective, caring, responsive and well-led services. All population groups were rated as good The full comprehensive report on the August 2016 inspection can be found by selecting the ‘all reports’ link for The Broadshires Health Centre on our website at www.cqc.org.uk.

This inspection was a desk-based exercise, accompanied by telephone interviews with four members of staff, carried out on 21 March 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breach in regulation that we identified in our previous inspection on 26 August 2016. This report covers our findings in relation to the requirements and improvements made since our last inspection.

We found the practice had made improvements since our last inspection. The information supplied by the practice, and telephone interviews carried out on 21 March 2017 confirmed the practice was meeting the regulation that had previously been breached. We have amended the rating for this practice to reflect these changes. 

Our key findings were as follows:

  • The provider kept practice specific clinical and operational policies and protocols under review. These were recorded when they were updated. Staff were aware of the location of policies and said they were easy to access.
  • There was an appropriate system in place to record and share the outcomes and learning from significant events. Staff we spoke with were able to identify learning from significant events that had occurred since the last inspection.
  • The procedure for dealing with a break in the cold chain (the procedure for keeping medicines requiring a controlled temperature safe) had been updated. We saw minutes of meetings showed the new procedure had been shared with staff and those we spoke with knew how to manage a break in the cold chain if this occurred.
  • There was a system in place to ensure minutes of staff team and practice meetings were shared with all staff.
  • Nationally reported performance data for 2015/16 showed the practice had increased the number of face to face reviews for patients diagnosed with dementia from 78% to 91%. This was above the clinical commissioning group (CCG) average of 87% and national average of 84%. This had been achieved with the practice only removing 2% of patients from this indicator which was below the CCG average of 5% and national average of 7%.
  • The practice sought patient feedback by various means and acted upon the feedback received. Issues and proposed developments were shared with the online patient participation group (PPG) members. This group were encouraged to comment on practice and local health care developments. A suggestion box was available as well as a comments area on the practice website. The common theme in patient feedback was availability of appointments. The practice undertook a daily review of appointment availability and varied the mix of pre-bookable and on the day appointments to respond to this feedback.
  • Patient feedback to staff and via the patient comments and suggestion box showed that evening appointments were appreciated by patients of working age who found it difficult to attend for appointments during normal working hours. The practice responded by appointing a further GP to undertake evening clinics and funded this by obtaining GP access funds.

The rating for the provision of safe services has been updated based on the findings of this desk-based exercise. The overall rating of good remains unchanged.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

26 August 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Broadshires Health Centre on 26 August 2016. Overall the practice is rated as good. However, the practice is rated as requires improvement for provision of safe services.

Our key findings across all the areas we inspected were as follows:

  • There was an open and transparent approach to safety.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients said they found it easy to make an appointment with a named GP, within a week of request, and there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the duty of candour.
  • The practice hosted a range of NHS and private health services as well as providing a base for groups that offered social and benefits support and advice for patients.

  • The practice had a system in place to check and record the temperatures of vaccine fridges. However, we found that one fridge had been operating above the recommended temperature range. Staff had not taken action to ascertain why this was the case or to have the fridge checked to ensure it was working properly. Vaccines could have been compromised.

  • The practice held a range of policies and procedures relevant to the management of the service. We found that a number of these policies had no recorded review in the last three years. The practice could not be sure these policies were up to date and reflected current practice.

  • Minutes of meetings held to discuss learning from significant events were not always made available to GPs and nurses who did not attend review meetings..

The areas where the provider must make improvement are:

  • Ensure all staff involved in the checking of medicine fridge temperatures are aware of, and follow, the practice procedure for taking action on out of range temperature readings.

  • Ensure documented outcomes from reviews of significant events and complaints are brought to the attention of both GPs and practice nursing staff who do not attend review meetings.

The areas where the provider should make improvement are:

  • Consider means of increasing the number of face to face care reviews for patients diagnosed with dementia.

  • Ensure all policies relevant to the management of the service are reviewed and the review documented in accordance with the practice policy review schedule.

  • Review the mechanisms for receiving and acting upon patient feedback. Consider ways of encouraging greater involvement of their PPG in shaping the delivery of services going forward.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice